HOSPITAL POLLUTION PREVENTION
CASE STUDY
by ,
Science Applications International Corporation
McLean, V-irginia 22102
EPA Contract No. 68-C8-0062
Project Officer
Kenneth R. Stone
Waste Minimization, Destruction
and Disposal Research Division
Risk Reduction Engineering Laboratory
Cincinnati, Ohio 45268
This study was conducted in cooperation with
U.S. Department of Veterans Affairs
RISK REDUCTION ENGINEERING LABORATORY
OFFICE OF RESEARCH AND DEVELOPMENT
U. S. ENVIRONMENTAL PROTECTION AGENCY
CINCINNATI, OHIO 45268
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DISCLAIMER
.... |
This material has been funded wholly or in part by the United States Environmental Protection Agency under
contract 68-C8-0062 to SAIG. It has been subject to the Agency's review and it has been approved for publication as an
EPA document. Mention of trade names or commercial products does not constitute endorsement or recommendation
for use. I
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FOREWORD
Today's rapidly developing and changing technologies and industrial products and practices frequently carry
with them the increased generation of materials that, if improperly dealt with, can threaten both public health and the
environment. The U.S. Environmental Protection Agency is charged by Congress with protecting the Nation's land, air,
and water resources. Under a mandate of national environmental laws, the agency strives to formulate and implement
actions leading to a compatible balance between human activities and the ability of natural systems to support and
nurture life. These laws direct the EPA to perform research to define our environmental problems,; measure the impacts,
and search for solutions. !
The Risk Reduction Engineering Laboratory is responsible for planning, implementing, and managing research,
development, and demonstration programs to provide an authoritative, defensible engineering basis in support of the
policies, programs, and regulations of the EPA with respect to drinking water, wastewater, pesticide's, toxic substances,
solid and hazardous wastes, and Superfund-related activities. This publication is one of the products of that research and
provides a vital communication link between the researcher and the user community. ;
In order to effectively implement its pollution prevention programs, the EPA is also investigating how the
departments and agencies within the Federal community can help each other reduce their generation of wastes. As a
part of these efforts, RREL provides staff and support to conduct waste minimization assessments under the Waste
Reduction Evaluations and Assessments at Federal Sites (WREAFS) Program. Under the WREAFS program, the U.S.
Department of Veterans Affairs Cincinnati - Fort Thomas Medical Center (DVA-Cin) offered to host an assessment of
pollution prevention opportunities at their facility. The DVA-Cin study investigated the use of disposables in patient care
in order to identify research opportunities for future solid waste minimization. ;
E. Timothy Oppelt, Director
Risk Reduction Engineering Laboratory
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ABSTRACT
t . !
[
- .- . - - i-
In order to effectively implement its pollution prevention programs, the EPA is also investigating how
the departments and agencies within the Federal community can help each other reduce their generation of
wastes. As a part of these efforts, RREL provides staff and support to conduct waste minimization
assessments under the Waste Reduction Evaluations and Assessments at Federal Sites (WREAFS) Program.
Under the WREAFS program, the U.S. Department of Veterans Affairs Cincinnati - Fort Thomas Medical
Center (DVA-Cin) offered to host an assessment of pollution prevention opportunities at their facility. The
D VA-Cin study investigated the use of disposables in patient care in order to identify research opportunities
for future solid waste minimization. s
; i
i
This report was submitted in fulfillment of 68-C8-0062 by Science Applications International under the
sponsorship of the U.S. Environmental Protection Agency. This report covers a period from August 1989 to
April 1990 and was completed as of May 1991.
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CONTENTS
1. Foreword I... iii
2. Abstract :.... iv.
3. Figures vi
4. Tables ,.... vii
5. Introduction I... 1
Background i
Project methodology 2
Findings 3
Recommendations 4
Organization of this report 5
6. Site Visit 6
. General facility description 6
Methodology r ... g
Site visit results "... 14
7. Pollution Prevention Opportunities at Hospitals .' ,.... 34
Introduction ; ... 34
Increase in the use of disposables 34
Incentives for reducing costs 34
Barriers to reducing reliance on disposables 35
Reusable versus disposable products 38
Other opportunities for pollution prevention ; 1... 47
Elements of a successful pollution prevention program '.... 48
Appendices ]
A. Definition of regulated medical waste 50
B. Calculation of hemodialysis occupied beds '.... 51
C. Major generating wards in New Jersey hospitals 52
Glossary 53
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FIGURES
Number page ;
1 Waste handling procedures posted in soiled utility room ;.... 26
2 Disposable medical devices reported to be reused in |
descending order of frequency ;.... 36
3 General Guideline for reuse 37
4 Cost comparison of reusable versus disposable surgeon's pack ' 40
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TABLES I
Number Page \
1 Number of beds and occupancy rate 7
2 VA program task force , 8
3 Site of generation and treatment/disposal method ,
for medical supply waste stream : 10
4 Site visit agenda 8/16-17/89 VA Medical Center, Cincinnati 14
5 Laboratory services - prevalent "posted" disposable items !.... 18
6 Surgery - selected disposable purchase items ; ',.... 22
7 Surgical intensive care unit - selected disposable purchase items : 23
8 Surgical patient floor - selected disposable purchase items j.... 25
9 Medical intensive care unit - selected disposable purchase items .'../... j 28
10 Hemodialysis - selected disposable purchase items : 29
11 Outpatient clinic - selected disposable purchase items ,.... 31
12 Historical shift to disposable items ;.... 35
13 Comparison of supplies available in disposable and reusable form 39
Vii
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SECTION 1
INTRODUCTION
BACKGROUND
The United States Environmental Protection Agency (EPA) is promoting the implementation of
pollution prevention as a cost-effective tool toward reducing the discharge of both hazardous and non-
hazardous wastes. EPA's Risk Reduction Engineering Laboratory (RREL) is contributing to the
Agency's efforts in promoting pollution prevention by conducting research and demonstration projects
and programs.
As part of the Agency's efforts, RREL is conducting a series of pollution prevention assessments
and demonstrations as part of a program known as Waste Reduction Evaluations at Federal Sites
(WREAFS). The program involves conducting pollution prevention assessments at Federal facilities,
with an emphasis on facilities involved in production and/or manufacturing.
As part of the WREAFS program, pollution prevention opportunities were assessed at the
Department of Veterans Affairs' Cincinnati - Fort Thomas Medical Center (VA-Cin). This report serves
as a case study for identifying opportunities for pollution prevention in a hospital setting. The report is
based on the information gathered during a site visit to VA-Cin, additional materials provided by
officials of the VA-Cin facility, and a literature search.
Hospital costs have skyrocketed throughout this decade. Some analysts attribute the increased costs
in health care to the fact that the hospital's expenses are passed on to the patient and eventually
reimbursed by medical insurance. Consequently, because costs are passed on, there is a decreased
incentive to cut costs. Thus, hospitals may, in general, not readily recognize the cost benefits of
incorporating pollution prevention opportunities. VA facilities, alternatively, are not reimbursed for the
cost of health care services provided to patients, and therefore have an. inherent incentive for achieving
cost savings. From this perspective, conducting a pollution prevention case study at a VA hospital was
an excellent choice for determining pollution prevention possibilities in a hospital setting.
The VA-Cin Medical Center segregates its waste so as to nn'ninn>e the amount transported by the
infectious waste hauler (unit costs for infectious waste disposal far exceed unit costs for disposal of
general refuse). While extensive waste segregation may serve to minimize the amount of regulated
medical waste generated and reduce the hospital's overall disposal cost, it is not considered a form of
pollution prevention for purposes of this study. To qualify as pollution prevention, source reduction or
recycling must occur. That is, the total volume of waste generated (medical and non-medical) must be
reduced to achieve pollution prevention. ;
This study focuses on potential opportunities for minimizing the discarded medical supply
wastestream. The study did not consider waste reduction opportunities associated with office wastes,
cafeteria wastes, radioactive wastes, pharmaceutical wastes, or chemical/hazardous wastes. Although
reducing those wastestreams not investigated in this report is critical to a complete pollution prevention
effort, much of this information is available from other sources.
The remainder of the introduction provides a summary of project methodology, findings, and
recommendations. More detailed discussions of each of these topics appear in Sections 2 and 3.
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PROJECT METHODOLOGY j
In assessing pollution prevention opportunities for disposable medical supplies, several questions
had to be answered:
What type of disposable medical supplies are used in a hospital?
Who uses them? . ',
How are they used, treated, and disposed?
Can practices be changed to reduce the generation of disposables? i
By answering such questions, pollution prevention opportunities are evaluated through a "mass balance"
analysis. A mass or material balance assumes that the material entering a system will be equal to the
material leaving the system, plus the material accumulated. Material balances allow for realizing losses
that may have gone undetected if a waste stream was characterized based solely upon disposal
iniformation
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How are wastes disposed? '
In accordance with EPA's definition of pollution prevention, product substitution, recycling and reuse
are among the available approaches to pollution prevention. The case study team worked with ward staff
to define the list of supplies used (and re-used) in each ward and the method of treatment/disposal
employed by ward staff for various disposables. VA-Cin's infectious control practitioner completed a table
defining which wastes were disposed of as infectious waste by the facility and which were disposed of as
general trash. Also defined are the methods of waste treatment (i.e. autoclaving), if any, used in the
hospital.
Can practices be changed to reduce the reliance on disposables? i
As discussed in more detail in Section 3, the use of disposables became popular in hospitals about 10
to 15 years ago and, with the spreading of the acquired immune deficiency syndrome (AIDS), the use of
disposables has escalated in the last 2 to 3 years. VA-Cin Medical Center staff estimated that
approximately 80 percent of hospital supplies are now disposables, as compared to an estimated 20 to 30
percent 10 to 15 years ago. According to VA-Cin staff, the reasons for changing from reusables to
disposables include: convenience to the staff, improved quality assurance/quality control that can be
achieved at a central manufacturing facility, the absence of space and skilled staff to conduct re-processing,
and infection control concerns.
4 \
The case study team's research at medical libraries, including the National Library of Medicine
(NLM) in Bethesda, Maryland, revealed that professional journals aimed at hospital administrators, plant
engineers, nurses, and infection control practitioners have considered the general topic of substituting
reusables for disposables, and the possibility of reusing disposables. The literature revealed that factors
behind the medical profession's preference for disposables include: j
i
Cost - The use of disposables eliminates the costs associated with in-house reprocessing.
Convenience - Items such as disposable operating room packs provide all of th<5 needed materials
for a given procedure presterilized and prepackaged.
Labor shortages/wages - The manpower needed to reprocess reusables is eliminated along with
the costs associated with the labor.
Space constraints - Because disposable products can be ordered as they are needed, only limited
storage space is required.
Health and safety - Prepackaged and presterilized products reassure medical professionals of a
product's sterile integrity. ;
FINDINGS . i
The review of supply sheets indicated that the largest requisitioners of disposable supplies in the
hospital are the SPD (serving patient wards and the outpatient clinic), the laboratory, and the operating
room., This corresponded to the Chief of Acquisitions and Materials Management's estimation that 85 to
90 percent of disposables consumed by the hospital are used by these three wards/departments. This
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parallels the results of an earlier EPA study1 that reported that the largest sources of medical waste within
hospitals were: the laboratory, the operating room, and medical/surgical units (Appendix G). The case study
team focused its site visit on these three waste-generating wards/departments as well as the! inpatient and
outpatient wards.
Hospitals make use of a large number of disposable medical supplies. As mentioned above, reasons
for using disposables, as opposed to recyclables, include cost, convenience, labor shortages/wages, space
constraints, and health and safety factors. Two general types of disposable medical supplies are currently
used in hospitals: plastics and paper (non-woven) products. Plastics have replaced much of the glassware
previously found in hospitals. Hospitals have turned to plastic disposables for a variety of reasons, including
health and safety concerns. VA-Cin Medical Center staff, and the literature review, revealed almost uniform
reluctance to return to glassware. Thus, source reduction may not be possible. However, recycling
opportunities may exist for plasticware. i
The VA-Cin facility, unlike most hospitals, continues to make extensive use of wovens (as opposed to
disposable paper products) for items such as gowns and drapes. This practice is an extremely effective form
of pollution prevention. If paper products were used, the volume of material disposed would increase
greatly. '
.As a result of cost considerations, the VA Medical Center has not replaced wovens with paper/plastic
products. The facility has access to a VA operated laundry and continues to make use of that laundry.
However, even within the VA-Cin facility, there has been a recent interest, and increase, iri the use of pa per
gowns. Concern over worker health and safety, especially with the advent of AIDS, is the primary reason for
the increased use of paper hi hospitals, even when a facility has access to laundry services. Unlike
industrial/commercial facilities where cost serves as the primary incentive for pollution prevention, hi a
hospital setting, cost incentives are second to health and safety concerns. :
RECOMMENDATIONS ;
This study generally recommends that hospitals should review their lists of disposable medical supplies
and determine which of these disposable supplies can be replaced with reusables or whether disposables can
be reused after sterilization, without sacrificing safeguards to protect worker and patient health and safety.
Where source reduction is not possible, recycling opportunities should be investigated. Current literature
suggests that there are innumerable concerns associated with reuse of medical supplies. The basic rule has
been to reuse supplies where risks of infection are judged to be sufficiently low, and costs make reuse viable.
However, the literature suggests that as a result of the multitude of factors involved in making the
decision of disposable versus reusables (including functional reliability, legal arid liability issues, economics,
work place hazards, and ethics), health care institutions must make their decisions on an individual basis. The
Medical Center's Commodity Standardization Committee offers an ideal forum to review opportunities for
pollution prevention. While other concerns such as health, safety, cost, or convenience may be at issue,
opportunities to undertake pollution prevention should be considered. Specific recommendations are
provided in Section 3.
'Characterization of Medical Waste Generation, Treatment and Disposal Practices in New York and New Jersey.' USEPA Region II,
January 30, 1989. This document is alternatively referred to as the NY/NJ study in this report '
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ORGANIZATION OF THIS REPORT !
The remainder of this report is divided into two sections. The next section provides the
information gathered from the site visit conducted at the VA-Cin Medical Center and includes lists of
the major disposable supplies used in each waste-generating ward observed and how those supplies are
currently treated and disposed. The information reported in Section 2 includes observations made by the
case study team and statements made by VA-Cin staff. The final section describes the opportunities and
limitations for minimising the disposable medical supply wastestream. ,
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SECTION 2
SITE VISIT
GENERAL FACILITY DESCRIPTION 1.
t.
The Veteran Affairs' Medical Center in Cincinnati (VA-Cin) is a government-owned, general medical
and surgical hospital offering four principal areas of service: medical, surgical, psychiatrical, and
neurological The facility maintains 415 authorized and 342 operating beds. The Medical Center is large
relative to other private and government-owned hospitals. In the same manner that hospital size is
expressed in terms of number of beds, hospital waste generation studies express generation rates in terms
of volume of waste generated per occupied bed. !
Table 1 lists the number of beds and occupancy rates for the Medical Center's four major service areas.
As shown, the medical and surgical service departments maintain 246 beds, with approximately 128
occupied or 52 percent occupancy. The American Hospital Association (AHA) determined the national
average to be 65 percent occupancy for general hospitals and 73.2 percent occupancy for Federal general
hospitals (Hospital Statistics. AHA, 1988). According to facility staff, the relatively low ioccupancy rate at
the VA Medical Center is partly a result of the lack of available nursing staff for all of the patient beds.
The VA-Cin facility provides outpatient services for approximately 500 individuals per day. The
outpatient clinic conducts medical exams and surgical procedures and its sections include chemotherapy,
dermatology, ear, nose and throat (ENT), orthopedics, plastic surgery, and urology.
In addition to the medical waste generated through inpatient and outpatient services, the VA-Cin facility
also manages wastes for an associated research facility, nursing home, and home health; care services.
METHODOLOGY \
I
As stated in Section 1, the case study assessment team conducted the pollution prevention opportunity
review using a mass balance approach. Such an approach requires that each component of a process be
evaluated. To achieve this objective, a program task force was established by the VA-Cin. The task force
included hospital employees involved with supply, use, treatment, and disposal activities; at the Medical
Center.
At the initial meeting between the EPA and the VA task force, the following task force representatives
were present
«> Chief, Building Management Services (Chair)
«> Assistant Chief, Building Management Services (EPA contact) i
« Infectious Control Practitioner > - ' '
« Industrial Hygienist j
o Facility Engineer.
In addition to these representatives, an industrial hygienist from VA Headquarters in Washington, D.C.
attended as an observer. Individual task force members and their professional responsibilities are listed
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TABLE 1. NUMBER OF BEDS AND OCCUPANCY RATE*
Service/Ward
Medical Services
Patient Floors
MICU/CCU
Heinodiatysis Unit
Inactive Ward
Total
Surgical Services
Patient Floors
SICU
GU/Orthopedics
Neurosurgery
Inactive Ward
Total
Total
Psychiatric Services
Neurology
TOTAL
Number of
Operating Beds
74
8
9
33
124
32
8
37
12
33
122
246
75
24
345
Number of
Occupied Beds
47
8
6.2"
Q
61.2
30.5e
7
18
11'
0
66.5
127.7
70
17
214.7
Average
Occupancy Rate (%)
!
__
i
49.4!
" !
;
i
i
54.5!
51.9
99,3
70.8'
i
62.2
'SOURCES: Medical
Center Bed Status Reoort
Period Ending Midnight, Tuesday June 27, 1989 (VA
Medial Administration Service) and Site Visit Interviews.
bSee Appendix B for calculation of hemodialysis occupied beds.
"The site visit estimate was 30-31 occupied beds.
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TABLE 2. VA PROGRAM TASK FORCE
Task Force Member
Raynold Cole (Task Force Chair)
Patrick Barry
Ron Sollberger
Dave Ninneman
Linda Danko
Professional Responsibility
Chief, Building Management Services
Assistant Chief, Building Management Services
Industrial Hygienist
Plant Engineer
Infectious Control Practitioner
in Table 2. Each of the members was selected to serve on the program task force based on their
responsibility for waste management services within the hospital Among other things:
Building Management Services is responsible for collection of wastes within the hospital including
laundering; -
Engineering is responsible for establishing contracts with waste haulers, and for operation of the
facility incinerator; and .
The Infectious Control Practitioner and Industrial Hygienist are responsible for establishing
policies and ensuring compliance with waste handling procedures.
Notably absent from the program task force were professionals responsible for the ordering and
distribution of medical supplies throughout the facility. Program task force members associated with
Building Management Services and the Infectious Control Practitioner also served on the facility's
Commodity Standardization Committee. The Commodity Standardization Committeje is responsible for
reviewing products currently in use or of potential use, in the hospital from cost, comfort, safety and
convenience perspectives. As the authority to implement new products resides with jthe Committee, the
ultimate success of any pollution prevention effort would necessarily involve consideration of pollution
prevention objectives by the Commodity Standardization Committee. .!
As described in the EPA Waste Minimization Opportunity Assessment Manual, the initial
responsibilities of the program task force are:
1) Obtain a commitment from management
2) Establish priorities for assessing the wastestreams or facility areas ;
3) Select case study assessment team
4) Conduct (or supervise) assessment
In addition, at the completion of the assessment, the task force's responsibilities include defining
pollution prevention goals, conducting further detailed evaluations of technical/economic feasibility,
selecting options for implementation, obtaining all necessary funding, and monitoring performance.
Given these responsibilities, the importance of integration between the program task force and the
Commodities Standardization Committee becomes more apparent The following briefly describe!! how
the program task force executed each of the four aforementioned initial tasks:
1) Obtain a commitment from management: From the onset, VA-Cin officials showed strong
support for a pollution prevention opportunity assessment. Their commitment and interest: was
immediately manifested in their offer to charter the task force. >
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2) Establish priorities for assessing wastestreams or facility areas: Much of the initial meeting, and
subsequent conversations between EPA and the VA-Cin facility, concerned which hospital wastes
should be the focus of the assessment. Disposable medical supplies were selected as the waste of
interest. In addition, the site assessment focused in on those wards/departments ordering the
majority of disposable supplies. (
3) Select case study team: The task force chair assigned the Assistant Chief of Building Management
Services to be the hospital's representative on the case study team. Other members of the team
included two EPA .staff members, two contract employees, and an outside obsjerver. In addition,
as the case study team progressed through each ward/department, a designated hospital staff
member, familiar with the activities within that ward/department, provided assistance and pertinent
information. I
4) Conduct (or supervise") assessment: The case study team's schedule and access to VA staff and
departments was managed by the Assistant Chief of Building Management Services. All
subsequent information requests were funneled through Building Management Services.
, -«- i
Following an initial meeting with the program task force, VA-Cin officials provided the following
materials to the case study team: -
1) A blueprint of the case study facility, clearly labeling various wards/departments, soiled utility
rooms (waste storage rooms), and treatment/disposal areas ;
2) A completed inventory (based on a checklist provided by EPA) of wastes generated at the facility,
along with waste handling methods ;
3) A listing of relevant VA-Cin policies !
4) Estimates of wastes burned in the facility's onsite incinerator, and
5) Estimates of wastes generated by ward/department
These documents, along with the information gathered during the meeting, were used to produce an
operations summary. The summary preliminarily identified the points of interest for the site visit:. The
two information sources most useful to the development of the operations summary were the completed
inventory of waste generation and treatment/disposal methods and the facility blueprint. These appear in,
Appendices B and E, respectively.
The VA-Cin infectuous waste control practitioner provided an inventory identifying areas within the
hospital where wastes are generated and how they are handled. She noted that the VA-Cin facility
defines its medical waste handling practices based on the Center of Disease Control's (CDC) Universal
Precautions of body substance isolation. Presently, the VA-Cin Medical Center categorizes its wastes
into five groups: general, chemotherapy, blood and body Quids, sharps, and radioactive. Determining
which category a waste falls in also dictates its manner of disposal Disposal methods include
contracting with an infectious waste hauler, contracting with a toxic waste hauler, making use of the
sewer system, sending wastes to an animal crematorium and autociaving materials oh-site prior to
disposal offsite by a waste hauler. The completed checklist (Appendix B) identifies: the waste category
of each waste, the ward generating each waste type, and the treatment/transport/disposal methods
employed. Based on this information, Table 3 was generated. It provides a list of disposable medical
supplies, the, generating ward, and the disposal method in use.
The information from the sight of generation/disposal method checklist, the facility blueprint and the
NJ/NY study, enabled the team to formulate a comprehensive operations summary. | , ,
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TABLE 3. SITE OF GENERATION AND TREATMENT/DISPOSAL METHODS
FOR MEDICAL SUPPLY WASTE STREAM |
DisposalWaste Waste
Method Category Type
I.
1.
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
C
C
C
C
G
G
.G
G
G
G
Q
G
C3
(3
G
G
G
1
1,
1
1,
1
1
1
1
4 Broken glass (depends what it contained)
4 Broken glass (depends what it contained)
6.1 Sanitary napkins, tampons
6.1 Bedding (respiratory isolation)
6.2 Bedding (strict isolation)
3 Blood components
3 Blood derivatives
3 Blood vials
2 Body fluid specimen containers (full)
4 Broken glass beakers (soiled and used in lab)
4 Broken glass flasks (soiled and used in lab)
4 Broken glass test tubes (soiled and used in lab)
4 Broken rigid plastic items (soiled and used in lab)
4 Cover slips
1 Culture dishes/devices to transfer, inoculate, mix cultures
1 Culture media
1 Cultures and stocks of medical and pathological labs
4 Glass blood vials
4 Glass culture dishes
3 IV bags - containing blood
4 Lancets
4 Pasteur pipettes
4 Slides
6.1 Specimen containers (respiratory isolation)
3 Test tubes
3 IV bags - containing cytotoxics
3 IV bags - containing cytotoxics
4 Syringes (with or without attached needle) - cytotoxic
4 Syringes (with or without attached needle) - cytotoxic
4 Syringes (with or without attached needle) - cytotoxic
2 Body fluid specimen containers (empty)
2 Body fluid specimen containers (empty)
2 Body fluid specimen containers (empty)
6.1 Bedpan (respiratory isolation)
6.1 Urinal (respiratory isolation)
6. 1 Enema bags (respiratory isolation)
6.1 Disposable diapers (respiratory isolation)
6. 1 Hot water bottle (respiratory isolation)
6.1 Gowns, booties, cap (respiratory isolation)
1 Clean up materials
3 IV bags - other (non-blood, -cytotoxic)
3 IV bags - other (non-blood, -cytotoxic)
4 Hypodermic needles
7 Hypodermic needles
7 Hypodermic needles
4 Hypodermic needles
4 Hypodermic needles
4 Instruments designed for cutting and puncturing - disposable
4 Instruments designed for cutting and puncturing - disposable
4 Instruments designed for cutting and puncturing - disposable
Ward
Patient care areas
Lab service
Patient care areas
Patient care areas
Patient care areas
Lab service
Lab service
Lab service
Lab servjce-inc.path
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Lab service
Patient care areas
Lab service
OR
Patient care areas
Patient care areas
OR
Pharmacy
OR
Lab service-inc.patrt
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Lab service
Patient care areas
OR
Patient care areas
Patient care areas
Pharmacy
Pharmacy
OR
Patient care areas
Lab service-path.
OR
continued
10
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TABLE 3. SITE OF GENERATION AND TREATMENT/DISPOSAL METHODS
FOR MEDICAL SUPPLY WASTE STREAM (Continued)
Disposal
Method
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH .
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
IJLJ
in
IH
IH
IH
IH
IH
IH
IH
IH
IH
IH
Waste Waste
Category Type
3 Dressings *
3 Dressings *
3 Dressings *
6.1 Drinking cups (respiratory isolation)
6.2 Drinking cups (strict isolation)
6.2 Enema bags (strict isolationXdisposable)
6. 1 Gauza (In contact w/ oral/nasal secretionsXresp isolation)
6.2 Gauza (strict isolation)
3 Gauza *
3 Gauza *
3 Gauze*
3 Gauza *
3 Gloves*
3 Gloves *
3 Gloves *
3 Gloves *
3 Gowns*
3 Gowns *
3 Gowns *
3 Gowns * .
6.2 Gowns, booties, cap (strict isolation)
6.2 Hot watar bottle (strict isolationXdisposable)
6.1 Maskg (respiratory isolationKwom by patient)
6.2 Masks (strict isolation)
3 Masks*
3 Masks*
3 Masks*
3 Masks*
3 Paper towels *
3 Paper towels*
6.2 Sanitary napkins, tampons
6.2 Specimen containers (strict isolation)
3 Surgical sponges *
. i 1 nermoviifnBr cuwns \respiraiory isolation}
6.2 Thermometer covers (strict isolation)
6.1 Tissue with nasal secretions (respiratory isolation)
6.2 Tissue with nasal secretions (strict isolation)
6.1 Toothbrushes (respiratory isolation)
6.2 Toothbrushes (strict isolation)
3 Underpads, disposable sheets *
3 Underpads. disposable sheets
3 Underpads, disposable sheets *
3 Underpads; Disposable sheets *
6.2 Urinal (strict isolartonXdisposabie)
Ward I
i
OR I
SICU
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
PEA ;
Clinic i
OR !
OR
Patient care areas
PEA \
Clinic
Clinic ;
Patient care areas
OR I
PEA i
Patient care areas
Patient care areas
Patient care areas
Patient care areas
OR
PEA i
Clinic \
Patient care areas
Patient care areas
Lab service
Patient care areas
Patient care areas
OR
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Patient care areas
Clinic
OR
Patient care areas
PEA :
Patient care areas
11
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TABLE 3. SITE OF GENERATION AND TREATMENT/DISPOSAL METHOD
FOR MEDICAL SUPPLY WASTE STREAM (CONTINUED)
KEY: ' .. i
. ' r
Waste Categories ,
1. Cultures and stocks of infectious agents and associated biologicals
2. Human pathological wastes ;
3. Liquid human blood, products of blood, items saturated and/or dripping with human blood or items
that were saturated and/or dripping with human blood that are now caked with dried human blood
4. Sharps that have been used in animal or patient care or treatment or in medical, research or
industrial laboratories ;
5. Contaminated animal carcasses, body parts, and bedding of animals that were known to have been
exposed to infectious agents during research (not included in scope of study)
6. Biological waste and discarded materials contaminated with blood, excretion, exucated or secretions
from humans who are isolated to protect others from certain highly communicable diseases, or
isolated humans who are isolated to protect others from highly communicable diseases
6.1 Involving Humans in Respiratory Isolation.
6.2 Involving Humans in Strict Isolation .
6.3 Involving Animals
7. Unused sharps
Disposal Methods :
G. General waste hauler ,
A. Autoclaved on station, then becomes general waste !
I. Incinerated on station j
H, Removed from station by liscensed infectious waste hauler
A Removed from station by an animal crematorium and cremated (not included in scope of study)
C. Removed from station by licensed cytotoxic waste hauler.
12
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An abbreviated checklist to guide case study team was developed prior to the site visit. The
checklist consisted of general questions, such as: :
1) The type of service provided and the number of patients or beds
2) Activity measures, such as the number of blood tests conducted
3) The rationale for the use of disposables versus reusables i
i
4) The potential for substituting disposables with reusables (and the advantages and disadvantages
of substitution)
5) Treatment/disposal methods used, and i
6) General trends in the use of disposables and reusables. '
\
Conducting the Site Visit
The site visit was conducted on August 16 and 17, 1989. The site visit agenda is presented in Table
4. Each ward/service was visited and questions were asked based on the checklist VA officials were
also afforded time to discuss other relevant issues beyond those raised as a result of the interview
checklist. '
* '
On Day 1, the case study team initially met with Supply, Purchasing, and Distribution (SPD) and
Acquisitions and Material Manifest (A&MM) to develop a better understanding of the supply and
distribution system within the hospital, and to ensure that questions were targeted properly. SPD and ;
A&MM professionals not only provided an overview of the hospitals supply and distribution systems, but
also provided historical background of the general trends in materials management over the past
30 years. !
Other areas visited on Day 1 included: |
Surgical Intensive Care Unit (SICU) :
Outpatient Clinic :
Medical Waste Storage Area i
Medical Intensive Care Unit (MICU), and \
Cardiac Care Unit (CCU) !
Day 2 consisted of visits to the medical waste storage area, the incinerator, patient floors, the
laboratory, hemodiarysis, and research wards/departments.
Upon completion of the site visit, additional information requested from VA-Cin officials included
the following: ;
1) Additional issue books and clarification of nomenclature in the issue books
2) The number, size, and originating ward of sharps boxes generated each week
13
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TABLE 4. SITE VISIT AGENDA 8/16-17/89
- VA Medical Center - Cincinnati
Day 1: Wednesday 8/16/89:
Department ,
Supply, Purchasing, and Distribution
Acquisition and Materials Mgmt.-
Surgery
Surgical Intensive Care Unit
Outpatient Clinic
Basement Storage Area
Medical Intensive Care Unit and
Cardiac Care Unit
Day 2: Thursday 8/17/89:
Basement Storage Area
Incinerator
Patient Floor
Laboratory
Histopathology
Hematology
Clinical Chemistry
Microbiology
Lab Supervisor
Hemodialysis
Research
Time
9:30-10:30
11:00-12:30
12:30-1:30
1:30-2:00
2:00-2:30
2:30-3:00
3:00-3:30
8:30
8:30-9:00
9:30-10:30
10:45-11:00
11:00-11:30
11:30-11:45
11:45-12:00
12:45-1:30
1:30-1:45
1:45-2:30
Contact
Zephy Cross
Paul Mang
Jeff Griffith, RN
Martha Harrisom, RN
Barbara Bales, FIN
Pat Barry
Judy Monroe, RN
Pat Barry
Rich Crene
Maria Behan, RN
Betty Williford
Pamela Dyer
Ken Mescher
Dr. Gilchrist
Dr. Copeland
Freda Cassidy
Judy Harrison
14
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3) The number of chemotherapy boxes generated by ward
4) The number of bags of blood and body fluid waste generated by ward, and
\
5) The number of Petri dishes, Vitex cards, and rapid RH panels ordered by the microbiology
laboratory. '
This information was essential in compiling a complete list of medical supplies used at the facility and in
identifying pollution prevention practices already in use at the facility.., <
SITE VISIT RESULTS !
Summaries of site visit results are presented below by ward/department The summaries are
presented in the order that the wards/departments were visited by the case study team. Each site visit
summary provides a list of the disposable medical supplies used in that ward or department as well as
the waste handling, treatment, and disposal practices employed there. In addition, each summary
includes an exhibit providing the number of disposable medical supplies ordered by that ward; the
quantity of each item ordered in a six month period; and whether or not the'Medical Center currently
disposes the named disposable supplies as infectious waste. '
i
SPD and A&MM '
Supply, Purchasing and Distribution (SPD) and Acquisition and Materials Management (A&MM)
were the first two departments visited by the case study team. Visiting these departments early in the ;
process was essential to the success of the opportunity assessment because it allowed the case study team
to understand more fully: - I
1) The degree to which the hospital made use of disposables; :
i
i
2) The primary uses of disposables in the hospital; ,
i
3) The factors contributing to the extensive use of disposables in a hospital environment; and
4) The opportunities for converting from disposables to reusables. .;
In addition, SPD and A&MM staff were extremely helpful in explaining the supply, purchasing, and
distribution system. Moreover, by gathering order sheets directly from SPD and A&MM, the case study
team was able to make more efficient use of the time allotted for interviews with ward/department
professional staff.
The following discussion summarizes results of meetings with SPD and A&MM staff. The four
issues stated above were investigated. '" ;
i
To what extent does the hospital use disposables? ,
The majority of waste generated by a hospital consists of disposable products. According to SPD
and A&MM, approximately 80% of the hospital's supplies are disposable (i.e., disposed after a single
use). Supplies ordered from the central warehouse are termed "posted." Eighty percent of the hospital's
supplies are posted, the remaining 20% of the hospital's orders are unposted (ordered directly from the
supplier). Exhibits in each of the following subsections present the major disposable items ordered by
i
15 . .''i
-------
Laboratory Services, Surgery, SICU, MICU, 5 South (a patient floor), Hemodiatysis, and the Outpatient
Clinic. These exhibits were generated from each ward's "issue book." Issue books list the supply orders
placed to the central warehouse by each ward/department \
i
The VA saw a change from reusables to disposables 10-15 years ago and an additional increase in
the use of disposables in the last 2-3 years as a result of the spread of the AIDS virus. The most recent
increase results from increased usage of existing disposable supplies (i.e. disposable gloves and masks),
rather than from the use of newly developed disposable items.
i
Which wards/departments are the major purchasers of disposables? !
i
i
The major purchasers of disposables at VA-Cin are in descending order: ,
Supply, Purchasing, and Distribution
Laboratory Services
Surgery. !
These three service areas together order approximately 85-90% of the hospital's disposables. SPD,
unlike the lab and OR, is not a user of supplies. Rather, it serves as a central distribution point for all
nursing services (inpatient floors and the outpatient clinic). \
What factors explain the extensive use of disposables in the hospital environment?
I
According to VA officials, the use of disposables reduces the potential for health risks, and .saves
time, money, and man-hours by eliminating the need for re-sterilization and re-processing. The fact that
the VA is not reimbursed for its health care services compels the Center's administrative staff to be
extremely cost-conscious. VA officials are convinced that disposables are less expensive than reusables in
many instances; consequently, cost is cited as the key reason for using disposables. In addition, hospital
personnel stated that most reusables are -no longer available as hospital supplies, although many reusable
products remain available to the home health care market
What opportunities for converting from disposables to reusables exist? '<
VA officials expressed their belief that it was unlikely that hospitals would convert back to the use
of reusables on a wholesale basis. Concern over worker health and safety and a belief that disposable
are more cost efficient are the major impediments to the return of reusables. Additionally, as mentioned
above, hospital supply companies no longer market many reusables, making large quantities of reusables
inaccessible to the hospital industry. ,
Still, pollution prevention is a reasonable objective in a hospital setting. The VA-Cin presently
uses wovens as opposed to disposable gowns, greatly reducing waste volumes. Another method for
reducing waste generation is through the reuse of disposables. While the VA-Cin employee training ;
course specifies that, for health and safety reasons, reuse of disposables is ill-advised, such reuse occurs
in the Medical Center, as well as other hospitals throughout the nation. In addition, recycling
opportunities may exist for plastics and glassware. Further discussion of pollution prevention
opportunities and limitations is provided in Section 3. '
Which wards/departments are the major users of disposables? '>
Laboratory Services i
The Laboratory Services Department performs analyses on specimens'taken from .patients
throughout the Medical Center. In a nine month period, ending June 30, 1989, the laboratory conducted
16
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41,097 venipunctures, 9,935 bacterial cultures, 4,730 blood cultures, 854 fungal cultures, and 815
tuberculosis cultures. The Laboratory consists of four separate areas: hematology, clinical chemistry,
microbiology, and histopathology. These areas are located on the second floor (Appendix E) of the
Medical Center.
The major items ordered from the hospital warehouse for use in the laboratories are presented in
Table 5. Included on the list are blood collecting tubes, surgical drainage tubes, needles, surgical
sponges, and gloves. Many items used in the laboratories are "unposted" (not supplied by the
warehouse) and, therefore, are not represented in Table 5. Commonly ordered "unposted" products are
discussed in the text The hematology, clinical chemistry, and microbiology laboratories are major users
of disposable medical supplies. Comparatively low volumes of disposable medical supplies are generated
by the histopathology laboratory.
All of the VA's laboratory wastes are currently placed in orange biohazard bags!, and autoclaved,
thereby rendering the wastes non-infectious and suitable for general trash disposal
Coffee cans lined with the biohazard bags are stationed at each technician's work area for use as
wane receptacles. Disposable plastic sharps containers will soon replace the use of coffee cans and
biohazard bags. This measure is being taken to reduce the risk of puncture injuries 'workers are exposed
to during routine maintenance of the coffee can setup (i.e. removing and transporting biohazard bags to
the autoclave room when they are full). The substitution will increase the volume of waste generated in
the laboratory to ensure occupational safety. This change exemplifies the trade off that occurs between
pollution prevention and safety in the health care arena (i.e. coffee cans will not be "recycled" for use as
waste receptacles because they do not offer the same level of protection from puncture wounds, and
associated risks of infection, as specially designed sharps containers).
Hematology Laboratory . j ;
The hematology laboratory draws and.anatyzes blood samples from 50-60 patients per day. The
technicians visit the patient floors and the outpatient clinic to draw blood samples, returning to the
hematology testing area to conduct the analyses. :
Cloth gowns are currently worn by staff when blood is drawn, and are replaced with a second cloth
gown for work in the laboratory. All gowns are laundered for reuse. To reduce the potential
occurrence of infection during visits to the patient floors and outpatient clinic, the laboratory is
considering requiring its technicians to use disposable gowns during floor visits. The paper gown would
then be discarded, and the technicians would continue to use cloth gowns while in the laboratory.
Waste Generation ;
Disposable products employed in the hematology laboratory include: test tubes (glass and plastic),
glass slides, needles, VACUTAINER blood collection sets, gauze, gloves, chucks (placed under
microscopes), pipettes (glass and plastic), plastic pipette tips, and other plastic testing items (e.g.,
cuvettes used to test blood coagulation).
The VA Medical Center generally disposes of infectious waste in three sizes of bags: 1 gallon (small),
5 gallon (medium), and 30 gallon (large). The hematology laboratory generates approximately 2 large
bags of autoclaved waste per day consisting in part of approximately 15-20 small bags of waste collected
from the work station coffee cans.
A blood bank, operated by an outside concern, is co-located with the hematology lab. The blood
bank uses disposable glass pipettes, wooden applicators, and plastic blood bags. As a result of its.
activities, the blood bank generates no more than one large bag of autoclaved waste: per w^sk.
17
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TABLE 5. LABORATORY SERVICES - PREVALENT "POSTED" DISPOSABLES ITEMS8
Purchase Item
Blood Collecting Tubes
(Glass)
Surgical Drainage Tubes
Urine Specimen Kit
Needles
Syringes
Gloves
Surgical Sponges
Drijssing/Bandages/Gauze
Adhesive Tapes
Facial Tissues
Number of
Itemsb
2
1
1
2
3
6
1
1
1
1
Number Ordered
in a 6 month
period
33,500
850
4,500
25,100
40
4,496
137,000
1,900
688
33,500
Disposed of as
Blood land Body
Fluid Waste
; No
:
No
; No
i No
I No
No
; No
No
! No
! No
Total number of items
represented
19
aThis list was generated from the Laboratory Services, January 1989-June 1989. Issue Books for ordering
supplies from the warehouse. Note that most of the laboratories' products are "unposted" (i.e., not
supplied by the warehouse).
( T
bN umber of items represents the number of varying items within the same category (i.e., there are two
different sizes of blood collecting tubes listed in the Issue Book... The table lists all sizes of the same
type under one name.
cSharps are autoclaved and incinerated on site. All other laboratory waste is autociaved and disposed of
as general trash. ,
d50% of the products ordered from the warehouse by Laboratory Services are listed in this Table. A
total of 38 items are ordered by Laboratory services from the warehouse.
18
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Haadling/Treatment/Disposal-
Each of the 5-6 work stations in the hematology laboratory are equipped with coffee cans lined
with small biohazard bags. Small disposable items, such as pipettes and pipette tips are placed in these
receptacles. When the cans are full, the liner bags are removed and delivered to the adjacent autoclave
room, and placed in the larger autoclavable bags. There is also a large bag in a trash canister located
next to the CBC machine (blood analyzer). This receptacle is used for the disposal of gauze squares
(used to remove test tube stoppers) and gloves that are worn during blood analysis. Approximately 1-2
gauze squares are used per sample. The receptacle is emptied periodically, and its contents are
autoclaved. As mentioned earlier, autoclaved waste is rendered non-infectious and placed in the general
trash. Used sharps, generated from drawing blood in patient or treatment rooms are placed in sharps
boxes mounted in each patient room. The hematology laboratory professionals are not responsible for
the disposal of these needles. The technician returns to 'the lab with only the samples and
VACUTAINER blood collection sets. The blood collection sets are dropped in the sharps boxes located
in 'the hematology lab. The sharps boxes are taken by housekeeping staff to the incinerator on the ninth
floor for weekly incineration.
Clinical Chemistry Laboratory ;
The clinical chemistry laboratory is housed in the same room as the hematology laboratory.
Professionals in this laboratory conduct blood serum and urine analyses. The samples analyzed in the
chemistry lab are drawn by the hematology technicians.
Waste Generation-
The generation of disposable medical supplies in the clinical chemistry lab is essentially equal in
volume to that which is generated by the hematology laboratory. Approximate waste generation rates of
the principal disposables employed in the clinical chemistry lab are listed below:
' . »
glass test tubes 2,100 per week
glass sample cups - 2,000 per week, !
dry reagent slides - 21,000 per week |
Waste generation rates of those disposables constituting a lesser volume of the total; wastestream include:
j
plastic cuvette rings - 25 per week '
urine sample containers - 280 per week
pipette tips - 140 per week
All, of the items used in the clinical chemistry laboratory are "unposted* items and thus, are not included
in Table 5. Because many of this laboratory's supplies have short shelf-lives (e.g., reagent slides), they
must be ordered directly from the suppliers. ;
l
The clinical chemistry lab generates 1.5 to 2 large bags of autoclaved waste per day.
Handling/Treatment/Disposal-
The waste from the hematology lab and the clinical chemistry lab are handled together and treated in
the adjacent autoclave room. The waste is packaged in orange biohazard bags, autoclaved, and then
placed in the general trash.
The cuvette rings, used for testing blood coagulation, are often washed and reused 5-10 times before
being disposed. These are the only disposable medical supply items that are reused;in this laboratory.
According to those interviewed, the high cost of the cuvette rings ($2.30 each) dictates their reuse prior
to disposal. ;
19
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Uncontaminated broken glass is placed in a cardboard box to prevent cuts or injuries. The cardboard
box is disposed of as general trash. Blood contaminated glass is autoclaved and then placed in
cairdboard boxes for general waste disposal
' , - I
Microbiology Laboratory .
i
This section of the laboratory generates the greatest amount of disposables by weight The weight of
the discarded supplies is due to the high volume of glass products disposed of in the microbiology lab.
Waste Generation-- !
According to the microbiology laboratory staff, disposable products comprise 98% of all their
autoclaved waste. At least 3 large bags of autoclaved waste are generated in the microbiology lab each
day. The principal disposable is glass Petri plates pre-prepared with agar, a culture media. ,
Approximately 1500 are disposed of weekly. Other autoclaved disposables include: ; blood culture
bottles, Vitek cards (used to identify bacteria - 225/week), contaminated slides, paper towels used to
clean work areas (per Universal Precautions), disposable gowns and gloves (needed in tuberculosis
isolation rooms), needles and syringes, and reagent strips (8/week). i
Handling/Treatment/Disposal- i
Contaminated wastes, such as Petri dishes, are disposed in trash barrels lined with large orange
biohazard bags. Coffee cans, lined with small biohazard bags, are located at each work station for small
objects such as Vitek cards. These wastes are autoclaved and then disposed of in the general trash.
Non-contaminated slides are placed in sharps containers and larger non-infected glass waste is placed.
in the covered cardboard box designated for discarded glassware. All other non-contaminated items are
disposed of directly in the general trash.
' *
Needles and syringes are autoclaved in sharps containers prior to incineration. Rh panels, used to
test the Rh factor in blood, are the only lab items disposed of as blood and body fljuid and consequently
transported by a licensed infectious waste hauler. The lab uses approximately 6 Rh panels each week.
The microbiology lab does not reuse any disposable products. Petri dishes are not reused because:
(1) they are difficult to clean property, without sacrificing the integrity of the product, and (2)
preparation of media is a labor intensive activity that can be achieved more cost effectively, and at a
higher standard of quality, by an offsite manufacturer. i
Histopathology Laboratory j
The histopathology laboratory, located on the second floor (Appendix E), is responsible for analyzing
tissue specimens and body parts from surgery and the morgue. ;
Waste Generation \
While this laboratory generates volumes of biopsy waste and body parts, it uses a limited number of
disposable items. They include: ;
i
physicians' gloves
paper towels ,
specimen bags (Ziploc bags), and ,
specimen containers. ;
No more than one medium-sized, 5 gallon bag of autoclaved waste is generated per day.
20
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Handling/Treatment/Disposal-
The disposable items listed above are autdclaved and rendered non-infectious, and disposed of in the
general trash. Pathological wastes are incinerated onsite. Disposable specimen containers containing
formaldehyde are autoclaved prior to incineration. ;
i
Sureerv Department
i
The Surgery Department handles approximately IS cases per day. According to VA officials, the VA
hospital is .one of the last hospitals in Cincinnati to use reusable woven gowns. Surgery staff attributed
the use of wovens in the VA-Cin Medical Center to the relatively low number of daily cases.
Waste Generation- !
According to Surgery personnel, the greatest volume of disposable medical supplies used and disposed
of in Surgery are lap sponges. (Note, however, that Table 6 shows that exam gloves are ordered in
greater quantities.) In the past, Surgery reused lap sponges prior to disposal However, due to concerns
of AIDS infection, Surgery currently uses single-use sponges. Other disposables from Surgery include
procedure products that are found in operating room packs. These packs are generally used in full,
although some items may never be used. Safety, quality assurance and product availability are three
major concerns providing the impetus for disposable, operating room packs.
Table 6, compiled from Surgery's issue book, presents several of the major items ordered through the
hospital warehouse. The primary items used are exam gloves, surgical sponges, surgical knife blades,
syringes, needles, masks, and dressings/bandages.
The Medical Center's Surgery Department generates 1-2 large bags of blood and body fluid waste per
case, or 15-30 bags per day. Approximately 1-1.5 bags per case is estimated to be paper waste (e.g.,
drapes) while, according to VA officials, other hospitals generate approximately 3 bags per case. The ;
lower generation rate at the VA was attributed to their continued use of woven materials.
11
Handling/Treatment/Disposal - '
The VA's Surgery Department is presently minimizing the generation of wastes through the extensive
use of wovens. Surgery also carefully segregates wastes as they are generated. Waste to be disposed of
as blood and body fluids waste must be "grossly contaminated" (i.e., soaked or dripping with blood). The
VA. Infection Control Practitioner explained that the facility is considering reducing the amount of
segregation at the point of generation in Surgery to increase efficiency. As she explained, the
surgeons and nurses should not be burdened with choosing the correct receptacle for each disposable
during surgical procedures. The move toward reduced segregation may change the way waste is
managed, but should have no effect on the overall rate of waste generation. i
Sharps are segregated and placed in sharps containers which are clear-bagged, put in short-term
storage and then taken to the onsite incinerator. Blood and body fluid waste from the operating room
is brought to the storage room in the basement and then transported by the infectious waste hauler to
the final treatment and disposal site. All other waste is disposed of as general trash!.
Surgical Intensive Care Unit CSICLT) ;
The SICU has 8 beds on the ward, 7-8 of which are occupied on a regular basis. ; Cloth gowns are
worn by patients and hospital staff and laundered for reuse. Some sterile gowns are required in the
SICU. These are sterilized by SPD after being laundered. Procedure trays (e.g., tracheotomy trays) ire
also sent to SPD for sterilization and returned to SICU for reuse. SICU staff expressed an interest in
switching to the use of disposable trays (increasing waste generation volume), because prepared trays
would be more convenient to the nursing staff. '
21
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TABLE 6. SURGERY - SELECTED DISPOSABLE PURCHASE ITEMS8
Purchase Item
Number of
Itemsb
Number Ordered
in a 6 month
period
Disposed of as
Blood and Body
Fluid Waste
Surgical Sponges
Exam Gloves
Surgical Knife Blades
Needles
Syringes
Surgical Mask
Paper Aprons
Dressings/Bandages
Catheters/Tubing
Disposable Surgical Pack
Specimen Bottle (plastic,
disposable)
Total number of items
represented6
5
2
4
9
1
1
12
8
1
1
45
16,000
20,900
3,900
1,200
2,435
1350
0
1,612
-834
0
24
Yes (if blood-
soaked)
Yes
No
No
No
No
Yes (if
blood-
soaked)
Yes
Usually
Yes
Sent to
labora-
tory
aThis list was generated from Surgery's January 1989»* 1989 Issue Books for ordering supplies from
the warehouse.
i
bNumber of items represents the number of varying items within the same category (i.e. there are two
different sizes of blood collected tubes listed in the issue book. The table lists all sizes of the same type
under one name.
°72jS% of the products ordered from the warehouse by Surgery are represented in this Table. A total of
62 items are ordered by Surgery from the warehouse.
22
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TABLE 7. SURGICAL INTENSIVE CARE UNIT - SELECTED DISPOSABLE PURCHASE ITEMS3
Purchase Item
Tubes/Catheters
Suction Equipment
IV Sets
Needles
Syringes
Total Number of Itemsd
Number of
Itemsb
24
2
2
7
2
~37
Number Ordered
in a 6 month
period
3,061
2,634
277
9309
1,882
Disposed of as
Blood 'and Body
Fluid0 Waste
Yes
; Yes
No
; -NO
No
1
i
]
3 SICU is supplied through SPD. This list was generated from SPD's supply distribution lists. Items
selected were those listed as major disposables by the SICU RN during the site visit
|
b Number of items represents the number of varying items within the same category (i.e. there are two
different sizes of blood collecting tubes listed in the Issue Book. The table lists all sizes of the same
type under one name. '
i
c Note that waste not usually treated as blood and body fluids waste will be treated as such from when
it is derived from strict isolation patients and from some respiratory isolation patients.
d 24.3% of the products ordered from the warehouse by SICU are represented in this Table. A total of
152 items are ordered by SICU from tfie warehouse. j
23
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Waste Generation- ;
SICU orders its supplies through Nursing Services which, in turn, receives supplies from SPD. The
principal items ordered through SPD are listed in Table 7. While over 152 separate items are ordered
by SICU, the 37 items listed represent a sizeable proportion of the total number of supplies ordered.
The 37 items include 24 different types of tubes/catheters, suction equipment, IV sets, needles and
syringes. ;
Blood and body fluid waste generated in the SICU consists mainly of suction liners and tubes. Foley
bags and chest tubes are flushed of their fluids and disposed of in the general trash.: IV bags are placed
directly in the general trash receptacle. SICU also generates needles and syringes. These are disposed of
in sharps boxes and are incinerated onsite.
Blood and body, fluid wastes are strictly segregated into 1-2 large bags per day. The SICU RN
estimated that one medium-sized sharps box is generated per bedside per day. The waste generation rate
can greatly increase with isolation patients. For example, the SICU may generate 10 medium sized bags
of medical waste for one isolation patient in one day. The number of isolation patients varies greatly
over time. . ;
Handling/Treatment/Disposal- !
Waste generated in patient rooms is segregated into three categories: (1) sharps,: (2) blood and body
fluids, and (3) general trash. Per general hospital practice, the blood and body fluid' waste is taken to
the basement storage area to be transported by the infectious waste hauler.
Sharps boxes are removed from the rooms when they are approximately three-quarters full. The
sharps containers are then taken to the incinerator. ,
Patient_Fjoors ! ;
"""^^" I
The surgical patient floor visited (located on the fifth floor, south side, otherwise! known as 5 South)
has 36 authorized beds, only 32 of which are in operating service due to staffing Shortages. The RN
estimated that 29-32 beds are occupied at any given time. This ward provides pre- and post-operative
nursing care to inpatients. Such care includes administering medication and changing dressings. The
other patient floors (i.e., medical patient floors) provide similar care to non-surgery patients. Each head
nurse is responsible for all activities within his/her own ward, including ordering supplies and overseeing
waste segregation activities. In total, the medical and surgical patient floors have 106 operating beds
with approximately 78 occupied at any given time (Table 1). ;
Waste Generation ......
Wastes generated in patient rooms are segregated into three categories: (1) sharps, (2) blood and
body fluids, and (3) general trash. Products disposed as blood and body fluid waste include wall
suctioning bags, tubing, and blood transfusion waste.
Table 8 lists the principal items ordered through SPD by 5 South. Dressing supplies are ordered
most frequently followed by disposable linen protectors (chucks), tubes/catheters, and wall suctioning
equipment The head nurse of 5 South estimated that 85-90% of their supplies are;disposable.
The head nurse also estimated that 5 South generates 1-2 large bags of blood and body fluid waste
per day. Other patient floors may vary slightly in their waste generation rates, depending on the type of
care administered. i
Handling/Treatment/Disposal- :
Sharps containers are mounted in each room and on the nurses' medication carts. There is a
receptacle for general trash in each patient room, and the blood and body fluid waste container is
i
' ' ' 24 . I
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TABLE 8. SURGICAL PATIENT FLOOR (5 SOUTH) - SELECTED DISPOSABLE PURCHASE ITEMS3
Purchase Item
Tubes/Catheters
Dressing Supplies
Wall Suctioning (bags/trays)
Liiien Protectors (chucks)
Total Number of Itemsd
Number of
Itemsb
16
10
3
1
^~30
Number Ordered
in a 6 month
period
3388
22,418
881
5,877 -
Disposed of as
Blood and Body
Fluid0 Waste
i Yes
; No
i Yes
No
i
a Patient floors are supplied through SPD. This list was generated from SPD's supply distribution lists.
The items selected for this table were listed as major disposables by the RN during the site visit.
b Number of items represents the number of varying items within the same category (i.e. there are two
different sizes of blood collecting tubes listed in the Issue Book. The table lists all sizes of the same
type under one name. !
i
c Note that waste not usually treated as blood and body fluids waste will be treated as such when it is
derived from strict isolation patients and from some respiratory isolation patients j
d 21% of the products ordered from the warehouse by 5 South are represented in this table. A total of
143 items are ordered by 5 South front the warehouse. :
25
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FIGURE 1. WASTE HANDLING PROCEDURES POSTED IN SOILED UTILITY ROOM
Regular Trash
Suction catheters
IV TBG
Suction TBG
ETTs
Chucks with blood
Bedpans
Urinate
Blood & Body Fluid Cap
Suction canisters
Hemovacs
Jackson-Pratt drains
Blood admin. TBG
Full rectal drainage bags
Dressings soiled
Anything with a volume of ..
body fluid contained
Only the above can be in the
blood & body fluid can -
it is paid for by the pound.
Use plastic covers on every PT on the bedscale.
Use plastic lab specimen bags.
Only use' Staphene on things that do not come in contact with a patient
Drain (wear a gown and doves
Urine !
Stool - liquid
Turp urine j
Gomco contents
Melena stool
26
-------
located in the soiled utility room. Figure 1, posted to provide instructions on appropriate waste handling
procedures, appeared in a soiled utility room on the 5th Floor. It lists those items to be disposed of as blood
and body fluids waste, regular trash, and those that should be disposed of down the drain. In practice, as a
matter of convenience, the nurses often dispose of non-blood and body fluid waste in the blood and body
fluid waste container. i
IV bags are to be disposed of in the general trash per hospital guidelines, althougluthey are often found
discarded in the blood and body fluid waste container. Cloth gowns are generally worn on the floors; when
cloth gowns are unavailable, disposable gowns are used by the staff. Disposable gowns contaminated with
blood should be disposed of in the blood and body fluid canister. However, used gowns are sometimes
placed in the general trash cans in the patient rooms. ' |
Medical Intensive Care Unit/Cardiac Care Unit (Mldl/CCU) !
i
The MICU/CCU has 8 authorized beds, and normally operates at 100% occupancy. This ward provides
nursing services for patients requiring close medical attention. \
Waste Generation--
Disposable products employed in the MICU/CCU include, but are not limited to: blood and suction
canisters, needles, syringes, paper masks, and chucks. The numbers of items ordered appear in Table 9.
The two reusable items employed in the MICU/CCU are cotton gowns and pressure bags. The former is
laundered and reused and the latter, a bag often used to introduce blood into a patient, is washed out and
reused. The RN interviewed during the site assessment observed that not much further opportunity for
switching to reusables exists. i
The MICU/CCU generates approximately one large bag of blood and body fluid waste per week.
Handlimg/Treatment/Disposal" ' ;
Wastes are segregated into the same three categories as in the other wards: (1) sharps, (2) blood and
body fluids, and (3) general trash. Sharps are disposed of in sharps boxes and incinerated ohsite. All
remaining waste generated in the MICU/CCU is placed in the general trash per hospital procedures.
However, the assessment team observed that, as mentioned above, waste not meeting the definition of blood
and body fluid wastes is discarded in the blood and body fluids containers. For example, empty, disposable
urinals were seen in the blood and body fluid containers. !
Hemodialvsis ; .
The hemodialysis unit has 9 treatment stations. Treatment is not continuous but occurs in shifts. The
treatment schedule is presented below: ;
o Monday, Wednesday, Friday - AM shift - 8 patients
- PM shift - 8 patients j
o Tuesday, Thursday - AM shift - 7 patients. '
Each treatment takes approximately 5 hours.
I
Waste-Generation- !
Nearly all products used in the hemodialysis unit are disposable. Each treatment involves at least: 2 IV
bags, 2 tubes, 2 needles, one pair of gloves, and significant amounts of adhesive tape. The hemodialysis unit
uses disposable aprons and masks as well. A list of disposable supplies used in the
27
-------
TABLE 9. MEDICAL INTENSIVE CARE UNIT - SELECTED DISPOSABLE PURCHASE ITEMS3
Number Ordered Disposed of as
Number of in a 6 month Blood land Body
Purchase Item
Tubes/Catheters
Suction/Collection Bags
Needles
Syringes
Linen Protectors (chucks)
Face Masks
Total Number of Items4
Itemsb
37
15
8
5
1
1
~67
period
8,222
4,760
9,059
2316
7,999 ,
40
aThis list was generated from SPD's supply and distribution lists. The
RN during the site visit as major wastes generated.
bN umber of items represents the
different sizes of blood collecting
type under one name.
number of varying items
tubes listed in the Issue
Fluidc; Waste
Yes
i Yes
; No
< No
: No
No
f
\
items selected were listed by the
i
within the same category (i.e. there are two
Book. The
table lists all sizes of the same
1
°Note that waste not usually treated as blood and body fluids will be treated as such when it is derived
from when it is derived strict isolation patients and from some respiratory isolation patients.
d3Q.6% of the products ordered from the'warehouse by MICU are represented in this Table. A total of
219 items are ordered by MICU from the warehouse.
28
-------
TABLE 10. HEMODIALYSIS - SELECTED DISPOSABLE PURCHASE ITEMS3
Number Ordered Disposed of as
Purchase Item
'Gloves
Needles
Blood Collecting Tubes
Adhesive Tape
Masks
Plastic Disposable Lab
Apron
Number of
Itemsb
5
4
2
2
1
1
in a 6 month Blood and Body Fluid
period Waste
13,112
8,900
1,400
672
1,900
5
Yes
No
Yes
Yes
Yes
Yes
Total Number of Items0
15
aThis list was generated from the Hemodialysis Issue Books (January 1989-June 1989).
bNumber of items represents the number of varying items within the same category (i.e. there are two
different sizes of blood collecting tubes listed in the Issue Book. The table lists ail sizes of the same
type under one name. ,
C28.8% of the products ordered from the warehouse by Hemodialysis are represented in this Table. A
touil of 52 items are ordered by Hemodialysis from the warehouse. }
29
-------
hemodiatysis unit can be found in Table 10.
The unit makes use of disposable diatyzers. However, as is common in many hospitals, the dialyzers
are sterilized and reused. In this hospital, staff estimated that dialyzers were used 20; times before
disposal The reuse of dialyzers reduces the volume of waste generated, and thus, provides a means of
minimizing waste. The practice of reusing disposables is a controversial issue in the;health care industry
and is discussed further in Section 3. At least 4 large bags of blood and body fluid $re generated per
day in the hemodialysis ward. i
Handling/Treatment/Disposal- |
Most of the disposable items mentioned above and those that are listed in Table 10 are discarded in
the blood and body fluids receptacle located in a soiled utility room in the unit Needles are placed in
sharps containers for onsite incineration. * :
Outpatient Clinic ! '
-* - .1
i
The outpatient clinic, located on the first floor (see Appendix E), provides services to approximately
509 patients per day. The services provided at the clinic include: surgical procedures, medical exams,
chemotherapy, dermatology, urology, plastic surgery, orthopedics and ear, nose, and throat (ENT).
Waste Generation- . .
Ninety percent of the supplies used in the outpatient clinic are disposable. The major disposable ,
items used are dressing materials and suction liners. However, as identified in Table 11, the outpatient
clinic orders over 800 different disposable items from SPD. Most of the clinic's "unposted* supplies
comprise reusable instruments that are sent to SPD for sterilization prior to reuse. ;
Plastic-coated paper gowns are used by staff members administering chemotherapy treatment
According to the RN, they are also worn for all other outpatient treatments and procedures. Although
the RN related that the paper gowns were being used for all or most outpatient treatments (rather than
just for chemotherapy treatments), this usage is not reflected in the number of paper gowns ordered in a
6 month period (Table 11). Paper gowns used during chemotherapy treatments are Disposed of with the
cytotoxic wastes, and the gowns worn while administering general treatments are disposed of with the
blood and body fluids, if they are considered contaminated. The RN interviewed believed disposables are
being employed in the clinic for greater ease and reduced risk of injury/infection to the Medical (Center
staff. ,
Reusable wovens that are commonly used include sheets, pillow cases, towels, and blankets. Although
wovens should always be laundered and reused, the RN reported that the staff frequently discards very
soiled linens.
Gomco suction apparatus, suture removal sets, and scalpels are all reused. Although general suction
equipment and rubber tubings were reused in the past, disposable suction liners arej now employed.
One large bag blood and body fluid waste is generated by the clinic per day.
Handling/Treatment/Disposal- '
Each procedure room has a mounted sharps box and a small waste container for general trash. Blood
an;d body fluid waste bags :are kept in the clinic's soiled utility room. The clinic's head nurse is
considering putting blood and body fluid bags in each procedure room per OSHA'si recommendation.
i
Chemotherapy wastes are packaged in white plastic containers, stored in. the same basement storage
areas where blood and body fluid waste is stored prior to pick-up, and transported for disposal by a
licensed cytotoxic waste hauler. |
30 ,.;
-------
TABLE 11. OUTPATIENT CLINIC - SELECTED DISPOSAL PURCHASE ITEMS3
Purchase Item
Dressing/Bandage/Gauze
Suction Liners
Suracal Masks
Number of
Itemsb
74
10
4
Number Ordered Disposed of as
in a 6 month Blood and Body Fluid
period Waste
17,608
696
', Yes (if blood
soaked)
Yes
: No
Plastic-Coated Paper
Gowns (Chemotherapy Gowns)
Total Number of Items0
76
90
No
(Chemotherapy)
aThis list was generated from SPD's supply and distribution and represents the sum of the products
ordered for each area of the clinic ;
"See Exhibit 2-6. .
r
C10.7% of the products ordered from the warehouse by the Outpatient Clinic are represented in this
Table. A total of 840 items are ordered by the Outpatient Clinic from the warehouse.
31
-------
Incinerator i'
i
The Medical Center's incinerator is located on the ninth floor. Sharps, pathological wastes, and
expired pharmacy drugs are incinerated every Friday. The capacity of the incinerator is not great enough
to accommodate any additional waste, and, consequently the hospital is expecting to build a new
incinerator within one year with increased capacity ,to accommodate all of the hospital's medical waste,
thus eliminating the need to contract with waste haulers. ;
Sharps Generation- ;
The pollution prevention case study team counted 14 medium-sized sharp boxes, containing mostly
needles and syringes, and 3 large boxes containing blood transfusion waste stored in the ninth floor
storage room. The sharp containers were enclosed in clear plastic bags. According :to VA officials, the
number of sharps boxes burned in a typical week is fairly consistent The numbers of boxes incinerated
over two previous weeks are shown below: - * ";
Number of Containers Number of Containers
Sharps Container Incinerated for the Incinerated for the
Size Week Ending 6/30/89 Week Ending 7/21/89
1 ' . i
small 3 ..... 2 .
medium 35 45 .
large .8 7
According to VA officials, on average, small sharps containers weigh 1.5 pounds,1 medium sharps
containers weigh 4 pounds and large sharps containers weigh 10.5 pounds. Using the figures from the
weeks ending 6/30/89 and 7/21/89 the average weight of used sharps incinerated each week was calculated
to be 242.5 pounds.
Storage Area - I
The storage room for blood and body fluid waste and cytotoxic wastes is located in the basement,
adjacent to the general trash loading dock. The blood and body fluid waste, generally packaged in large
brown plastic garbage bags, is transported by housekeeping from the soiled utility rooms to the basement
storage area. The brown bags are then placed in cardboard boxes which are lined with red biohazard
bags. These packaging materials are supplied by the contracted transporter. The blood and body fluid
waste is picked up every Thursday and transported ofisite to be incinerated at a commercial
treatment/disposal facility. The hospital is charged $ JO per pound of blood and body fluid waste
transported for disposal. j
Waste Generation- !
According to previously conducted studies, hospitals generate between 13 and 15 pounds of solid
waste per patient per day, with infectious waste comprising between 5 and 15 percent of the volume.
Infectious waste generation estimates from various studies indicate generation rates: between 0.5 and 4
Ibs. per occupied bed/day.1 The VA-Cin facility generates approximately 2300 Ibs/month of blood and
body fluids and sharps, or approximately .60 Ibs/occupied bed/day. Of the 2300 Ibs/month estimate,
Results from the earlier referenced NY/NJ report estimated "average" generation rate of from 1.5 to
3 Ibs/occupied bed/day. A New York Department of Health Study (Infectious Waste: A Statewide Plan for
Treatment and Disposal 1988) estimated generation rates at 4 Ibs/occupied bed/day.; A 1983 study of North
Carolina's hospitals estimated a generation rate of 0.5 to 1.09 Ibs/bed/day (Rutala and Sarrubii "Management
of Infectious Waste from Hospitals", Infection Control. 1983).
32
-------
roughly 1300 Ibs consists of blood and body fluids waste and the remaining 1,000 Ibs. consists of sharps
(and sharps containers). Thus, at a rate of roughly .60 Ibs/day for each occupied bedl, the VA-Cin facility
has a lower infectious waste generation rate than reported in many of the above mentioned studies.
However, this is not necessarily indicative of the hospital's success in pollution prevention.
!
The numbers are probably not comparable due to inconsistencies in how hospitals define what
constitutes infectious waste. These inconsistencies are most apparent in that most hospitals consider the
laboratory the greatest single source (approximately 30-31% of total medical waste according to the
NY/NJ study) of infectious waste, whereas, the VA-Cin classifies the majority of its laboratory's waste as
general trash upon autoclaving.2 On the other hand, the Medical Center's extensive use of woven
products is at least partly responsible for the relatively low infectious waste generation rate.
2Inflating the VA-Cin's quantity of medical waste to reflect the absence of lab waste in the count would
yield approximately 0.87 Ibs/occupied bed/day. This figure remains low compared to waiste volume generation
rates experienced by other hospitals. I
33
-------
SECTIONS |
POLLUTION PREVENTION OPPORTUNITIES AT HOSPITALS
INTRODUCTION
r
The purpose of this section is to identify, discuss and evaluate the feasibility of and opportunities
for minimizing waste in a hospital setting. Through a review of available literature, ;the VA hospital site
visit, and an understanding of the limitations facing waste reduction in a hospital setting,
recommendations for realizing pollution prevention opportunities, are made wffh regard to product
substitution, the reuse of disposables, and recycling. j
-^ :
INCREASE IN THE USE OF DISPOSABLES
i
The use of disposables in health care facilities has increased steadily over the last thirty yean; (see
Table 12). Since the 1950*s, hospitals have been replacing items and devices originally made out of
glass, metal, rubber and woven textiles with plastic and paper, single-use, disposable!products. The
application of a cost-plus basis for health care institution reimbursement in the 196Q's and 1970's, an
increase in inpatient care services and the advent of the plastics revolution all factored in ushering in
disposables.
Reimbursement of hospitals on a cost-plus basis provided an incentive to introduce new products
and services that improved diagnostic, surgical and/or therapeutic capabilities. At the same time, because
little money was invested to streamline operational efficiency or increase productivity, no active incentive
existed to upgrade basic services. One operation which suffered from this lack of funds was the hospital
laundry. Inpatient services increased during this period, creating new demands for all linen products.
Antiquated laundry operations were unable to keep pace with the expanding burden, and, consequently,
the facilities were often unable to efficiently process and sterilize the soiled linens. 'Disposables provided
health care institutions with a convenient solution. Replacing linens with disposables ensured an
adequate supply of required products and simultaneously relieved an overburdened laundry operation.1
As a result of the rapidly expanding plastics industry, many hospital devices including syringes,
gloves, tubing and catheters could be made cheaply and sold prepackaged and presterilized. Although
the per item cost for disposable products was high, the cost based reimbursement policy encouraged the
use of disposables. Guaranteed availability and decreased labor costs resulted in disposables largely
replacing reusables in health care facilities. As technology advanced, more intricate; instruments were
able to be mass-produced and sold as single-use items. The critical function of these high-tech devices
required that they be unquestionably sterile and reliable. The availability of prepackaged and
presterilized devices solved the quality assurance problem hospitals were facing and the single-use items
quickly replaced their reusable counterparts. ;
INCENTIVES FOR REDUCING COSTS ;
Rapidly rising health care costs over the past decade, paralleled by the increasing costs associated
with single-use items, have led to a call for cost containment and consequently, a reassessment of the
reusable versus disposable products issue. Hospitals have been forced to consider every alternative for
saving money without sacrificing the quality and integrity of their medical services. Operational
1 "Reusable Linens: An Economical Alternative to Disposables," Hospital Material Management
Quarterly/February 1984. pp. 7-26. ;
34 J
-------
TABLE 12.
Year
1958
1968
1983
1988
HISTORICAL SHIFT TO
Generation Rate
(Ibs/day/bed)
7.0
12.0
13.0
20.0
DISPOSABLE ITEMS2
Source
Clarisse, 1958
Davis, 1968
North Carolina
Hospitals
NYSDOH
inefficiencies are now being evaluated and remedied, triggering the development of new procedures and
programs to increase productivity and lower material and labor cost As the cost of solid waste disposal
(including incineration) goes up, particularly the disposal costs for medical waste, the reintroduction of
reusables may be warranted. The cost of medical waste disposal can be as high as S.90 per pound (S.30
at the VA-Cin facility). ' ,
Hospital automation, specifically in the processing and sterilization of soiled linens, over the past
few years is enabling many institutions to reconsider the use of reusable surgical' linens as a cost-
effective option to the disposal of paper products. |
Hospitals and other health care facilities have also attempted to reduce costs by reprocessing ;
disposable, "single-use" devices. Figure 2 provides a list of the most commonly reused, single-use devices
and reveals the prevalence of this practice in hospitals today. The reuse of single-use items is a much
studied issue and is given considerable attention in the field of medicine. Committees such as the
Association for the Advancement of Medical Instrumentation (AAMI) that develop standards,
recommend practices, and prepare technical information reports on medical devices also develop
operating practices for reuse. Documents regarding the reuse of disposables are available for many
specific devices (such as AAMFs "Reuse of Hemodialyzers,") and reviews of the issue are common in
medical journals. . ' ; .
Although the issue of reusing disposable devices is highly debated, health care professional;} agree
that if a product is to be reused, the reprocessed product must be as functional, sterile and safe as it was
when it was new. The factors which must be considered when making the decision to reuse a single-use
product include possible contamination, increased liability, decreased functional reliability, compromised
patient safety and the associated costs. A health care facility must also determine if; their quality
assurance program is compatible with reprocessing disposable items, and if not, evaluate the economic
feasibility to make it so.
In general, the less critical an item, the greater the chance that it will be considered for reuse.
The reprocessing of equipment that has been removed from a pack but has not been used will generate
little anxiety while the reuse of a cardiac catheter is more disturbing. The line graph presented in
. .
2 Taken from "A Review of Reusable vs. Recyclable Medical Waste Generated by Medical Facilities,
New York City Department of Health, Environmental Health Services, April 1989. i
i
35 ' ' '.':
-------
FIGURE 2. DISPOSABLE MEDICAL DEVICES REPORTED TO BE REUSED IN DESCENDING
ORDER OF FREQUENCY3
Hemodialyzers (46%)
Cardiovascular catheters
and guidewires (31%)
Respiratory therapy
breathing circuits (18%)
Biopsy needles (17%)
Cautery devices (16%)
Anesthesia breathing
circuits (14%)
Endotracheal tubes (10%)
Suture staple removers (9%)
Syringes (9%)
Orthopedic appliances (7%)
Suction canisters (7%)
Tracheal tubes (6%)
Bovie cords (5%)
Esophageal thermometers (4%)
External pacemaker
electrodes (4%)
Arterial catheter
needles , (2%)
Aseptic irrigating
syringes (2%)
Shunt connectors (2%)
Sterile skin scribes (2%)
Cholangiographic
catheters (1%)
Esophageal stethoscopes (1%)
Pacemakers
Pulmonary nebulizers
Skin staplers
Urinary catheter plugs
Allen needles
Arterial embolectomy
catheters
Condensing bottles
Operating room clamps
Ear syringes.
Face tents
Gastric pH monitors
Hypodermic needles...
Javid tubes
Oxygen masks
Microscalpels
Stone baskets
Surgical gloves
Triadaptors
Tracheostomy tubes
Urethral stents
Urinary bags
(1%)
(1%)
(1%)
(1%)
3 "Reuse of Disposable Medical Devices in the 1980's," Proceedings of the International Conference.
Institute for Health Policy Analysis, Georgetown University Medical Center, 1984, Appendix B.
36
-------
Fijjure 3 illustrates this concept As the criticalness1 of an item increases and the potential for infection
increases, the likelihood that an item will be reused decreases. For example, point A represents a
bedpan. Because the item is considered non-critical by CDC definition and the risk1 for disease
transmission is minimal, reuse would be considered. An arterial embolectomy catheter, alternatively,
would be considered critical and the potential for exposure to infection great Therefore, generally this
item would not be considered for reuse. In the end, safety takes precedence economics and pollution
prevention in a health care environment A hospital should consider each item separately to determine
the effects of reprocessing on the integrity of the product before making a decision about reuse.
Figure 3 General Guideline for Reuse
critical
Criticalness 8em|.Crttlcal"
of
Device
non-critical
Kay:
A -bedpan
8 - arterial embolectomy
_ catheter
AB - decreasing likelihood
of reuse
low
high
Potential Risk of Disease
Transmission
BARKERS TO REDUCING RELIANCE ON DISPOSABLES
When considering reusables and the- reuse of disposables as a means for reducing the amount of
waste generated in the hospital infection control represents a limiting factor. The threat of AIDS,
hepatitis B 'and other infectious diseases associated with blood borne pathogens, has made necessary the
implementation of guidelines in the health care arena which minimize the possibility of transmission.
The Center for Disease Control's (CDC) Universal Precautions state that all visible;blood and body
substances must be treated as potentially infectious. Since the status of all patients' blood cannot be
known, precautionary measures should be taken at all times. The CDC's Universal Precautions reduce
the risk of infection by the consistent use of barriers. The recommendations followed by most hospitals
include the use of gloves, protective clothing, masks and eye protection when there is a possibility of
coming into contact with body substances. i
Further, the Occupational Safety and Health Administration (OSHA) has proposed a rule regarding
occupational exposure to blood borne pathogens. The proposed standard, published in the Federal
Register on May 30, 1989, follows closely the guidelines issued by CDC on Universal Precautions. The
rule states that personal protective equipment (PPE) must be worn if there is a potential for soiling;
fluid resistant PPE must be worn if there is a potential for splashing/spraying; and fluid proof PPE must
be worn if there is a potential for soaking. PPE includes gloves, gowns, masks, eye1 protection,
faceshields, foot coverings, and respiratory equipment The proposed rule further recognizes that the
regulations will increase the amount of waste entering the general waste stream "due to the increase in
the use of disposable PPE" (54 FR 23108). ;
According to the Center for Disease Control, a critical item is one that will enter the.yasular system
or any sterile area of the body. An item is semi-critical if it comes into contact with only intact mucous
membranes. A non-critical item is one that comes into contact only with intact skin.
37
-------
When considering the increasing frequency of AIDS and the seriousness of all infectious diseases,
health care facilities must be careful, when trying to reduce their generation of waste, to avoid conditions
where the sterile nature of an item may be compromised. i
A second barrier to converting to reusable devices is that reusable products may not be readily
available. In many cases, the development of disposable substitutes has completely eliminated the
market for reusable products, and consequently, the reusable form is either no longer manufactured or
only available through special-order medical supply companies. It was suggested during the site visit
interviews that this may be the case for many items such as steel bedpans. In addition, special-order
supply companies may not be able to guarantee the availability of a product over time or may not be
able to supply large quantities of any individual item. Furthermore, the costs associated with special-
order items may exceed budget limitations.
REUSABLE VERSUS DISPOSABLE PRODUCTS j
The many reasons disposables continue to be used in hospitals, despite increased disposal costs for .
infectious wastes include: -
the necessity of maintaining unquestionably sterile items for infection control
increased barrier protection for patients and employees
safety risks related to the reuse of glass or other breakable supplies
lack of adequate space, equipment and personnel to reprocess reusables i
better inventory control
liability concerns when using non-sterile items and ' ;
cost-effectiveness and other financial issues2.
r
Table 13 reviews the reasons for choosing the disposable alternative for a select set of supplies
available in 'both disposable and reusable-form and provides a cost comparison of these items. It should
be noted that the cost figures presented represent only the initial cost of the item and do not
incorporate disposal or reprocessing costs. :
Wovens versus Nonwovens: General Issues . I
Many of the issues outlined above are raised in examining a hospital's decision to use wovens or
paper products. The use of wovens would decrease the volume and weight of hospital waste
significantly. Therefore, employing wovens throughout the hospital should be given serious
consideration, and each of the reasons for choosing disposables re-evaluated. ;
Health care personnel often choose paper products to ensure the sterility of an item even though
wovens, when laundered at sufficiently high temperatures and sterilized, presents anjequally sanitary
product. Additionally, hospital employees generally view paper products as offering a more reliable
barrier against blood and body fluid penetration as well as better protection against;microbes.
Although concerns about contamination are valid, the commonly held belief that disposables offer
superior infection protection may not be justified. Reusable fabric can be treated and made water
repellent, thereby resisting blood and body fluid penetration, and testing has shown jthat the density of
such treated fabric provides an effective barrier to bacteria. Antimicrobial fabrics such as BioGuard
(Burlington Industries, South Carolina) are available and should be investigated. A recent study on
2 "A Review of Reusable vs. Recyclable Medical Waste Generated by Medical Facilities," NYC
Department of Health, Environmental Health Services, April 1989.
38
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TABLE 13. COMPARISON OF SUPPLIES AVAILABLE IN DISPOSABLE AND REUSABLE
FORM
Initial
Supply Reason for Disposable reusable
disposal cost ' cost
Syringes Labor savings S0.25 $30.00
(10 ml) Space savings ' j
Cost savings
Sterility . j
Petri dishes Labor savings S0.20 ! 52.80
Space savings (sterile)
Cost savings.
Sterility
4 \
Needles Labor savings S0.10 i $2.50
(l"-25" gauge) Better quality (sterile)
Sterility
i
Pipettes Convenience S0.17 | S6.63
(1 ml Labor savings (sterile)
Serological) Sterility i
. . i
>
Lab coats Safety $4.00 | $35.00
nosocomial infections at the University of Connecticut Medical Center determined that patient safety is
not compromised through the use of woven products. Researchers found that "disposable gowns hold
no advantage over reusables in preventing surgical wound contamination and infection."3
Moreover, the Association of Operating Room Nurses (AORN) recommends that surgical gown
material should be comfortable, durable, drapable and aseptic4 The advantages of woven material
include that it is nonabrasive and allows for freedom of movement; it is more puncture resistant than
papier, and it conforms to the patient's body, allowing for ease of maneuverability and examination.
And, as mentioned above, wovens are equal in asepticity to paper satisfying the fourth recommendation
of AORN. ; i
The use of wovens, when all costs are integrated, may also represent a better use of hospital
resources. A cost comparison of a reusable versus a disposable surgeon's gown pack; and the cost
computing figures used to obtain these figures is presented in Figure 4. The discrepancy between the
3 "Nonwoven Barrier Material Equal to Cotton," Hospital Infection Control. July 1985, p. 85.
'' ">
4 "Recommended Practices for Aseptic Barrier Materials for Surgical Gowns," AORN Journal. 1983, Vol.
37, no. 2, pp. 249-58. ;
39
-------
FIGURE 4. COST COMPARISON OF REUSABLE VERSUS DISPOSABLE SURGEON'S PACK5
Per-use cost ($">
Pack
Materials and
laundering
Inspection and
preparation
Sterilization
cost ($)
Per-pack
cost ($)
Disposable
Reusable
Gown
Towel
Wrapper
(Premier)
Wrapper
(Steri)
Total
0.37
0.07
0.14
0.15
0.73
1.19
.027
3.50
2.19
Item
,-:.. Cost Computing Formulas ;
Laundering and product cost-per-use calculations
Original Item Life
Purchase price weight Laundry cost Expectancy Total Cost
(S) (pounds)(per pound)* (washing) per use
Surgeon's 11.57 + (0.88 x $.25 x 75)
gown '
75
Absorbent 1.11 + (0.19 x $.25 x 50)
towel
50
Wrappers 3.13 + (0.43 x $.25 x 100)
(Premier)
100
Wrappers 432 + (038 x $.25 x 75)
(Steri)
75
Total Cost Per Use
'National average laundering cost per pound
037
0.07
0.14
0.15
$0.73
5 Taken from "Reusable Linens: An Economical Alternative to Disposables," Hospital Materials
Management Quarterly. Feb. 1988, pp. 17-26. ;
40
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FIGURE 4. COST COMPARISON OF REUSABLE VERSUS DISPOSABLE SURGEON'S PACK
(Continued)
Inspection. Folding. Preparation and Delivery Costs
i _ - - , r
Time required for one gown pack .17 hour (10 minutes)
Hourly wage, including fringe benefits S7.00/hr
Total cost per use: .17 x S7.00 - S1.19
Sterilization costs ,
Cost per load $5.39 ;
Percentage of load space gown pack occupies .05%
Total cost per use: .05 x $5.39 = $0.27 i
41
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cosits for the disposable pack and the reusable pack becomes even greater if disposal costs are included.
i
Although, in some cases, paper products will offer a superior basis for use in administering the
best and safest medical care, the universal use of paper products in any health care facility should be
avoided. To achieve waste reduction, a health care facility must evaluate each case in which paper
products are employed to determine if wovens could be employed as an equivalent substitute. Intended
use, risk of infection, and other task-specific factors should be considered in determining which
alternative, wovens or paper, best suits a particular application. Once a hospital-wide evaluation has
been conducted, paper products should be replaced with woven products wherever possible to achieve
maximum pollution prevention.
Wovens versus Nonwovens: Pollution Prevention Opportunities at the VA Hospital I
The VA Medical Center in Cincinnati currently uses woven gowns for both patients and stall in
most areas of the hospital including the laboratories, Surgery, Surgical Intensive Car^ Unit, patient
floors, and the Medical Intensive Care Unit/Cardiac Care Unit Although cloth gowns are presently
worn by hematology technicians for both patient floor visits and lab work, the laboratory is considering
switching to disposable gowns for use during patient floor visits. The change will be! made to reduce the
rislc of infection. Newer fabrics and fabric treatments may make a reusable gown a viable option.
!
Disposable gowns are also worn by staff for tuberculosis isolation room visits, and plastic coated
disposable gowns are worn by staff while administering chemotherapy treatments in the Outpatient
Clinic. More recently these plastic coated gowns have been worn increasingly by staff attending to other
outpatient treatments. This situation should be examined to determine the sudden interest in disposable
gowns. If the outpatient treatments have either low or no relative risk of disease transmission, the staff
should consider the use of cloth gowns whenever they are available. j
Hemodiarysis staff wear aprons during all patient treatments. This practice is Inecessitated by the
imsvitable exposure to blood during such-treatments, and consequently the need for a high level of staff
precaution and protection. Currently disposable aprons are used. The availability of an appropriate
reusable item should be investigated. '
Other woven products being employed by the VA include sheets, drapes and cloth instrument
wraps. The instrument wraps are used in the operating room and laundered for reuse. All masks used
by staff during patient care in strict isolation rooms, the medical intensive care unity hemodiarysis and
during surgery are paper. Because paper masks are relatively inexpensive, it would be an economic
burden for the hospital to return to woven masks. In addition, hospital staff may also be unwilling to
use cloth masks because of the perceived health risks associated with reusing face masks. Furthermore,
the residual chemicals which may remain from the laundering and sterilization process may be irritating,
as well as noxious.
In addition, chucks used throughout the hospital are made of paper and dispensable. Chucks act as
linen and surface protectors, absorbing body fluids and blood so that the linens that will be reused do
not become grouty soiled and so that surfaces are easier and safer to clean. The hbspital may want to
review the use of chucks throughout hospital and assess whether the availability of the product has led
to its use even where it is not necessary. j
Recently, a decision was made by the VA's Commodity Standardization Committee to purchase,
stock and issue plastic bed pillow covers (Minutes, Commodity Standardization Committee, February 2,
1989) Prior to this decision, woven pillow covers were the only type supplied. The arguments to
initiate the use of plastic covers included: a decreased risk of infection due to the increased prevention
of soil and moisture absorption; and decreased replacement costs for pillows through an extended life
due to the use of plastic covers. However, the decision to use plastic pillow covers will increase the
42
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waste generated by the hospital. As a pollution prevention alternative, the VA should consider that
vinyl/nylon laminate covers be purchased for pillows. Such a purchasing decision would extend the life
of the pillow, decrease the risk of infection in the same way the plastic covers would, and reduce waste
by continuing the use of woven pillow covers. In addition, the comfort of the patient would be
preserved. . j
Although no decision to use or not use a particular product should be based solely upon its effect
on waste generation, the Commodity Standardization Committee should consider requiring that the effect
on the generation of waste be included in the consideration of purchasing new products. Second, the
Committee may request that Committee members look to identify pollution prevention opportunities
which exist so that any product substitutions, fostering the reduction of waste, can be made.
The decision to delete plastic bed mattress covers from the SPD stock is an example of
implementing pollution prevention (Minutes, Commodity Standardization Committee, February 2, 1989).
Because the mattresses currently being used have a vinyl/nylon laminate cover that can be wiped clean,
the plastic mattress covers are not needed. Although the deletion of this product from SPO stock is
clearly a step toward pollution prevention, it is not identified as such. By identifying this decision as
one that reduces hospital waste, the concept and goal of pollution prevention is emphasized. Staff
awareness and understanding of a hospital's goal to minimize waste generation is a Crucial element in
attaining this goal. Incorporating pollution prevention assessments into the Commodity Standardization
Committees procedures will greatly increase the dissemination of pollution prevention goals.
The current use of wovens over disposables by the VA Hospital greatly reduces the volume of
waste generated. Additional opportunity for product substitution with respect to replacing paper
products with cloth products is limited due to the stringency of CDC and other infection control *
guidelines, as well as perceptual and cost considerations. The VA's use of wovens serves as an excellent
example for other hospitals implementing pollution prevention but who currently employ disposables. ;
Disposable versus Reusable Procedural Equipment: General Issues ,
A variety of disposable devices ranging from syringes and hemodialyzers, to Petri dishes and
bedpans further contribute to the growing waste streams generated by health care facilities. In the past,
many of these items were made from glass, steel, and rubber and were reused. With the issues raised by
the AIDS virus and a growing understanding of infectious diseases, concerns of transmission have led
many organizations such as CDC and OSHA to develop strict precautionary guidelines. The essentiality
of infection control in contemporary medicine often eliminates the opportunity to replace many single-
use items with reusables. i
Still, opportunities for substitution do exist To successfully reduce waste, it is important that a
hospital carefully revisit each site where the decision to use a single-use device has been made and re-
evaluate that determination. If a reusable product provides comparable function, sterility and safety, the
use of the disposable device should be reconsidered. For many of these products a; decision may also be
made with respect to reusing a single-use device.
Disposable versus Reusable Procedural Equipment: Pollution Prevention Opportunities at the VA
Hospital .
Because of the diversity of items included in this subsection it will be expedient to discuss
opportunities for pollution prevention by ward in the following discussion. The major disposable items
in each ward will be reviewed. . ;
Laboratories- !
Laboratory Services use essentially all disposable items. Many of these items; are glass products
<-
43 ':
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and include test tubes, sample cups, Petri dishes, slides, pipettes and pipette tips. Although glass can
be washed, autoclaved and reused, all glass used in the VA Hospital's laboratories is autoclaved and
disposed of after a single-use. This practice is employed by the hospital as a general safety practice to
reduce the risk of injury and exposure to infection. By immediately disposing of glass and other
breakable items, handling time is decreased, lessening the chance of exposure, to infection through spills
and breakage.
i
Glass products used in the Hematology and Clinical Chemistry laboratories are contaminated with
blood and body fluids, and therefore are to be considered potentially infectious per Universal
Precautions. The reprocessing of blood or body fluid contaminated items would increase worker
ex{>osure to bloodborne pathogens. Although it would be possible to reprocess and reuse some
glassware (e.g. slides), a proposed OSHA rule will require "glassware and hand instruments...to be
decontaminated prior to washing and/or reprocessing11 (54 FR 23121).- 'Such requirements will increase
labor and reprocessing costs to the point where reusing glassware may not be economically feasible.
i
The Microbiology Lab disposes of approximately 1500 glass Petri plates each week. Because they
are glass there is an opportunity to reprocess the dishes and reprepare them with media. Although this
would minimize waste to a large extent, Petri dishes are not reprocessed because they are difficult to
clean and reprocessing may sacrifice the integrity of the product Furthermore, preparation of the agar
is labor intensive. Still, it is important that the hospital consider reusing glass Petri' dishes. The
M<5dical Center should investigate the opportunity to have glass Petri dishes reprocessed off-site. Such
an alternative would allow the laboratory to continue operating efficiently, without the disruption of
implementing in-house reprocessing practices, and decrease significantly the amount of waste generated
by the laboratory. . ' ,
« ,
Plastic and other synthetic material products constitute a large pan of the remaining disposables
found in the laboratories. The principal disposables include pipettes, pipette tips, test tubes, testing ;
items, specimen bags and containers, urine specimen kits, and gloves. All of these items are autoclaved
and disposed of after a single-use. Pipettes, test tubes and specimen containers are all available in glass,
but as the hospital's policy now stands and due to the limitations mentioned above with respect to
infection control, such a substitution would provide little benefit and only increase waste disposal costs
due to an increase in the weight of the disposed products. The urine specimen kits are used for
convenience and provide all needed materials presterilized and prepackaged. Assured availability and
decreased labor costs associated with these packs has encouraged their use. Because of the convenience
of such kits, reusables are unlikely candidates for substitution. Over time, however,;as land filling and
incineration costs are expected to spiral in the future, reprocessing of glassware may prove an
economical alternative to plastic disposables. |
! . - '
Plastic testing items include Vitek cards, cuvette rings and RH panels. These! disposable items
were developed for their convenience. Reverting to reusables would drastically increase time, labor, and
associated costs. Reprocessing and reuse of disposable items, although generally practiced to keep costs
down, would present an alternative way to minimize wastes. The cuvette rings, disposable device!! used
to test blood coagulation, are reused five to ten times before they are discarded. Although they are
single-use items, they are reused because of their high cost As previously discussed in this Section, the
decision to reuse must be made on a product by product basis. For instance, the reuse of bedpaus (a
non-critical item) would be generally accepted and would reduce a hospital's waste generation rate.
Gloves contribute to the laboratory waste stream. Universal Precautions recommend that jjloves
should be worn when it is likely that hands will be in contact with body substances. In addition, in
accordance with CDC recommendations, the proposed OSHA rule mandates that disposable gloves will
not be washed or disinfected for reuse. CDC states in "Update: Universal Precautions for Prevention of
Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Blobdborae Pathogens in
Health care Settings," (June 24, 1988) that disinfecting agents may cause deterioration of the glove
' "44 ,i .
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material while washing with surfactants could result in enhanced penetration of liquids via undetected
holies. ' :
The remaining waste consists of syringes, needles, VACUTAINER blood collection sets, dressings,
bandages, gauze, adhesive tapes, facial tissues and paper towels. These constitute wastes which are
inevitably generated by any health care facility. Due to the high potential for disease transmission from
these items, they are currently disposed and there is no immediate prospect for product substitution.
Moreover, any contaminated paper product is likely to raise concerns of recyclers.
Surgery- :
Exam gloves and surgical sponges contribute the greatest number and volume of disposables to the
hospital's waste from Surgery. [It should be noted that in most hospitals paper gowns, drapes, and
instrument wraps constitute the greatest percentage of waste generated in the operating room.] The
VA's use of linens, although atypical, provides for an enormous reduction of waste.> As previously
discussed, it is imperative that gloves are used only one time and immediately discarded to maintain a
high level of infection control Surgical sponges are used during all operating procedures to soak up
blood and body fluids. Consequently, used sponges must be considered soiled by potentially infectious
fluids. Their immediate disposal reduces worker exposure to potential pathogens. Furthermore, the
absorbent quality of sponges makes reprocessing an unlikely option. Although sponges are essential
items, and there may be no viable substitute, hospital practices should be examined to discover if
sponges are being used in greater quantities than necessary or for activities which could alternatively use
absorbent, reusable towels (e.g., cleanup activities).
Surgical knife blades, syringes and needles are disposed of as sharps and incinerated at the
hospital. Because of the high risk of worker injury and disease transmission through cuts and puncture:
wounds associated with these items, CDC recommends the disposal of these items over reprocessing.
r
Because of the nature of surgical procedures and the absolute necessity of available and sterile
devices, operating room packs are often'used. Operating room packs are disposable and contain the
instruments and other materials needed for a given procedure. One of the reasons for using these packs
in lieu of assembling..the required reusable materials prior to each operation is a decrease in the labor
resources which must be devoted to both assembling new trays and reprocessing soiled procedure items.
The costs of presterilized, disposable trays are significantly lower than those associated with .collecting,
cleaning, sharpening, lubricating, inspecting, packaging and sterilizing the many items needed for a given
procedure. Although convenience is an important factor, assured availability and increased safety suggest
that the return to reusable procedure materials is unrealistic for contemporary medical practices. In the
past, the use of prepackaged procedure trays often resulted in needless waste, i.e., the disposal of unused
materials. Today, most surgical packs are very specialized so that all contents are generally employed
during a given procedure. Although it is not often the case that components of the packs or trays are
not used, the VA Medical Center repackages any unused devices for reuse. This achieves some level of
waste reduction without having to alter contemporary medical practices. i
The most significant waste reduction in the operating room will be achieved through general
housekeeping practices as discussed below.
Surgical Intensive Care Unit (SICU)/Medical Intensive Care Unit (MICU)6- ;
The major disposable products used in the SICU and MICU include catheters, tubing, suctioning
equipment, IV bags, needles, and syringes. Catheters, tubing, and suctioning equipment all come in
contact with body fluids during usage. Per Universal Precautions, these items when soiled are associated
6 Because the principal disposables used in the SICU and the MICU overlap to a great degree, they are
discussed together. ;
-, .
'45 ; :
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with a relatively high risk of disease transmission. The use of disposables limits worker exposure l:o
potential pathogens. In addition, the shapes of these devices make them difficult to clean. Patient
safety may be compromised if the integrity and sterility of such items are not assured. IV bags on the
other hand never come in direct contact with any body fluids and thus are not contaminated during use.
Plastic IV bottles, reusable for a single patient, should be considered as a substitute.j Glass IV bottles
are also available but the safety and ease of handling of the plastic bags make staff reluctant to consider
this option.
Patient Floors-
The disposable products regularly used on the patient floors include suctioning equipment, tubing,
catheters, blood transfusion equipment, and dressing supplies. Suctioning equipment, tubing, and
catheters are employed in the same way as in the SICU and MICU and thus have the same pollution
prevention opportunities discussed in the corresponding section.
Those items associated with the transfusion of blood must be handled and disposed of with
increased precautions due to their inherent contact with blood. Per Universal Precautions, a high risk of
disease transmission must be assumed. Consequently, neither the reuse of this equipment nor the use of
reusable equipment is recommended.
Considerations of infection control again limit the use of reusables as a means to pollution
prevention in isolation cases. Wastes.from strict and respiratory isolation rooms are contaminated with
diagnosed, transmittable pathogens. Because the consequences of transmission can be fatal, risk of
exposure to such viral agents must be minimized. Almost all disposable products are used and the
circumstances disallow reuse of single-use items. The use of reusables is also extremely restricted in
isolation cases to limit the number of and risk to employees who must handle the contaminated items. '
r
Hemodialvsis - : ;
Disposable products used in this ward include IV bags, tubing, needles, gloves and dialyzers. As
has; been consistently found throughout this review, little opportunity exists for pollution prevention by
way of reuse or product substitution of IV bags, tubing, needles and gloves. Dialyzers, though single-
use) items, are reused by the VA approximately 20 times before their disposal
The reuse of hemodialyzers has been found to be a common practice in health care institutions
today. In an informal survey conducted at the 1984 Georgetown University International Conference on
the reuse of disposables, 46% of the respondents reported that hemodialyzers were being reused in their
institution.7 Such reuse reduces the waste generated during hemodialysis treatments.
It should be recognized, however, that an evaluation must be made for each disposable which is
being considered for reuse. With respect to high-tech items, it is generally believed that hemodialyzers
are the only device that has been studied sufficiently to show that its function is not; impaired by
reprocessing.8 Such research determinations may encourage the reuse of hemodialyzers as a means of
acltieving waste reduction. Still reuse of single-use devices in any health care facility will be dependent
upon that facility's policy regarding reuse. Because other issues such as safety, ethics and even legality
are involved, it is important that these decisions are made according to hospital policy and not individual
staff member discretion.
7 "Reuse of Disposable Medical Devices in the 1980V Proceedings of the International Conference.
Institute for Health Policy Analysis, Georgetown University Medical Center, 1984, Appendix B.
8 "Single Use or Reuse: What's the Answer?" OR Manager. Oct. 1985, p. 6. ; :"
46 '' ' -
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Outpatient Clinic
Each of the disposable items employed in the Outpatient Clinic have been discussed individually
above. Principal disposables include dressing supplies and suction equipment
OTHER OPPORTUNITIES FOR POLLUTION PREVENTION !
The VA Hospital in Cincinnati has realized many of the opportunities for waste reduction chat
exist through product substitution. .The hospital's standard use of wovens has lead to a significant
decrease in the amount of waste it generates. This reduction of waste is exemplified by the
comparatively low number of bags of medical waste generated per case in the VA Hospital Surgeiy
Department Only one to two bags of medical waste are generated per case at the VA as compared to
the two to three bags of medical waste generated per case by hospitals that employ most or all
paper products in the operating room.9 In addition, the reuse of some disposable devices, where
functional integrity, sterility and patient safety are not compromised, has further reduced the hospital's
waste output The reprocessing of glass materials in the laboratories would reduce significantly the
hospital's rate of waste generation if such reprocessing was deemed feasible. Although further waste
reduction through product substitution is greatly limited by infection control guidelines, each disposable
product employed by a health care facility should be re-evaluated for pollution prevention opportunities.
In the end, each hospital must decide on its proper mix of disposables, durables, and reuse of
disposables, depending on its size, its reprocessing capability and its in-house quality assurance program.
The suggestions below focus on achieving pollution prevention through recycling and good
housekeeping, are applicable to all health care facilities, and are equally crucial to any successful
pollution prevention program as product substitution. : :
Recycling . ^
Although options for recycling are-limited, some glassware generated in the laboratories may
potentially be recycled. The recycling of glassware made from sodalime (e.g. pasteur pipettes) may
greatly reduce the volume and weight of a hospital's current wastes. Unfortunately,; a large percentage of
the glassware employed in the laboratory is made of pyrex (borosilicate) and can not be recycled with
other consumer glass wastes. Furthermore, although the autoclaving process completely disinfects, the
stigma which has been ascribed to medical waste may restrict or eliminate recycling;as a means of waste
reduction. Nevertheless, this alternative to disposal should be investigated; Community, county, and
commercial recycling centers should be consulted about their policies regarding the acceptance of glass
used in health care facilities.
Good Housekeeping j
Efficient and controlled management of materials is an essential element in the pollution
prevention effort It is important that accurate inventories are kept of stocked materials as well as
accurate numbers of noninventoried items that are requisitioned. By closely monitoring purchasing and
distribution operations, a hospital will be able to avoid both over-ordering and stocking materials no
longer used. Tracking materials from purchase through distribution also mitigates the problem of
supplies ending up in wards that do not use them. In addition, if a given product is overstocked in a
ward, materials tend to be used less conservatively and are often wasted. ;
Reusables should be employed whenever the option is available. For example, in the Outpatient
Clinic both woven and plastic-coated paper gowns are available. For most treatments, the cloth gown
9 Jeff Griffith, Per site visit interview, August 16, 1989
' 47
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provides a sufficient barrier against infection, and therefore snook! be toe primary gown worn by
outpatient staff. The use off paper gowns should be limited to those treatments, such as chemotherapy,
which require more stringent infection control and increased barrier protection. Policy regarding the
primary use of reusables should be defined and communicated to all staff. ,
Moreover, pollution prevention should be considered when making purchasing decisions.
Incorporating pollution prevention assessments into the decision-making process for purchasing supplies
would greatly foster the waste reduction goal through the ultimate purchase of a greater number of
reusables. The incorporation of such assessments into the Commodity Standardization Committee
meetings will also encourage staff awareness of the hospital's goal to minimize wastes. Employee
involvement will be critical in the operation of any pollution prevention program and will be further
discussed below. :
!
ELEMENTS OF A SUCCESSFUL POLLUTION PREVENTION PROGRAM
A successful pollution prevention program must begin with support from top management This
support should be clearly affirmed in a written statement and circulated among hospital staff, A
program must also be developed and dearly defined in a document explicitly identifying the program
goals and objectives. A commitment to evaluate and implement waste reduction opportunities should be
expressed. . j
Personnel training should be modified to include an orientation of the' pollution prevention
program. To ensure policy consistency, it is important that such training be standard and used
throughout the hospital regardless of the ward an employee will be servicing. The significance of the .
pollution prevention program wffl be best impressed on staff through an initial orientation and the ;
periodic distribution of materials highlighting the hospital's pollution prevention achievements. The use
of irewaids and incentives to encourage employee involvement should also be considered. ;
Changes over time in the amount of waste generated should be carefully tracked. This will allow
the hospital to identify new or changing opportunities for waste reduction and inform staff of the success
of the program. Periodically, a review of the program should be conducted to revise and update the
program to reflect changing conditions. Additionally, the exchange of pollution prevention information
both within a health care facility and between ouiside health care facilities should be encouraged.
A successful pollution prevention program will be founded upon these elements. They offer a
starting point for any waste reduction program, the ultimate success of which will depend upon a
facility's creativity and dedication, to minimfaing the amount of waste being generated.
Research and Development Opportunities :
Although pollution prevention opportunities may appear limited at first, the implementation of
alternatives whenever possible will, in sum, achieve significant waste reduction. In addition, greater
opportunities may be unvefled with further research. Identifying research needs to enhance pollution
prevention in tte health care industry is an important step in accomplishing waste reduction goals.
Suggestions foff research and development possibilities in the health care industry are presented below:
Costing The literature suggests there is some confusion as to the relative costs of reusables
and disposables. As noted earlier, the unit costs of a product do not necessarily represent the
entire cost realized by health care facilities. For disposables, one must also consider associated
disposal costs. Disposal costs can be expected to increase in the future as landfill and
incineration rules grow increasingly more stringent Similarly, in considering reusable costs,
one must account for reprocessing and storage costs. EPA may want to cpnduct cost studies
for certain health care products in cooperation with other Federal agencies, such as Veterans
i -
48
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Affairs and Health and Human Services.
Quality Assurance: As noted earlier, the literature review conducted for this study indicated
that many health care institutions are reusing disposables upon sterilization. However, there
are considerable legal and ethical issues associated with the decision to reuse disposables.
Among these are the manufacturer's admonishments against reuse. There is jagreement that, in
general, manufacturers can offer a higher surety of sterility than can the individual health care
facility. In addition, the products were not designed for reuse and may face some deterioration
over time from use to use. EPA may want to consider working with trade associations, and
other Federal agencies, such as the Food and Drug Administration, in reviewing technical,
legal, and policy impacts of reusing disposables. The ultimate goal would be a protocol for
reuse. ;
. Development of Reprocessing Capacity: As stated earlier, many hospitals |have lost their
reprocessing capabilities as a result of the disposable revolution. Space and labor constraints
appear to be the major impediments to returning to reprocessing, along with; a general
preference for the convenience of disposables. As health care cost containment gains ever
increasing attention, reprocessing may once again receive a cost-competitive edge. EPA could
explore, along with trade associations and other Federal agencies, the potential for re-
establishing the viability of reprocessing, perhaps by stimulating the development of
cooperative reprocessing service centers in areas with a high density of health care facilities.
. Developing Reusable Market: Certain bills in Congress amending the Resource
Conservation and Recovery Act (RCRA) will require that Federal agencies meet certain
objectives for use of recyclable products. The EPA and VA may want to work together in
developing procurement guidelines for the VA which will stimulate the production and
distribution of reusables and recyclables. This could lead to waste minimization technology
transfer opportunities throughout the health care community. ;
49
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APPENDIX A
The term medical waste has been defined by EPA in the course of a recent rulemaking. In
promtIgating standards for the Tracking and Management of Medical Waste (54 Federal Register 12371),
EPA differentiated between medical waste and regulated medical waste. The term "regulated medical waste"
is currently applicable in states (termed "covered states") in which the Medical Waste Tracking Act (MWTA)
is operable. These States include Connecticut (CT), New Jersey (NJ), New York (NY), FLhode Island (RI),
and the Commonwealth of Puerto Rico (PR). ,
As defined in the MWTA, the term regulated medical waste includes those wastes listed below. It is
apparent from this list that regulated medical waste (as defined by the MWTA) is comprised of contaminated
medical supplies, blood, other body fluids, body parts, and unused sharps. However, Ohio; is not a "covered
state", and since the VA-Cin hospital is not subject to the MWTA rules, the MWTA definition of regulated
medical waste was not used in this study to guide the evaluation of the volumes of medical waste generated.
DEFINITION OF REGULATED MEDICAL WASTE
Cultures and stocks of infectious agents and associated biologicals, including:! cultures from
medical and pathological laboratories; cultures and stocks of infectious agents from research and
industrial laboratories; wastes from the production of biologicals; discarded live and attenuated
vaccines; and culture dishes and devices used to transfer, inoculate, and mix cultures.
Human pathological wastes including tissues, organs, body parts, and body fluids that are
removed during surgery or autopsy, or other medical procedures, and specimens of body fluids
and their containers. ;
Human blood and blood products including (V) liquid waste human blood; (2) products of
blood; (3) items saturated and/or dripping with human blood; or (4) items that were saturated
and/or dripping with human blood that are now caked with dried human blood; including serum,
plasma, and other blood components, and their containers, which were used or intended for use
in either patient care, testing and laboratory analysis, or the development of Pharmaceuticals.
Intravenous bags are also included in this category. !
Sharps that have been used in animal or human patient care or treatment or!in medical,
research, or industrial laboratories, including hypodermic needles, syringes (with or without the
attached needle), pasteur pipettes, scalpel blades, blood vials, test tubes, needles with atta'ched
tubing, and culture dishes (regardless of presence of infectious agents). Also: included are other
types of broken or unbroken glassware that were in contact with infectious agents, such as used
slides and cover slips.
Contaminated animal carcasses, body parts, and bedding of animals that were
been exposed to infectious agents during research (including research in ve
production of biologicals, or testing of Pharmaceuticals.
known to have
terinary hospitals),
Isolation waste: biological waste and discarded materials contaminated with
exudates, or secretions from humans who are isolated to protect others from
communicable diseases, or isolated animals known to be infected with highly communicable
diseases.
blood, excretion,
highly
o Unused sharps: hypodermic needles, suture needles, syringes, and scalpel blades.
so
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APPENDIXB I
* , *
CALCULATION OF HEMODIALYSIS OCCUPIED BEDS
1
Since hemodialysis beds are the only beds in this table that are not set up for overnight use, the following
calculation was done to equate the use of hemodialysis beds with the use of overnight beds, (i.e., the number of
occupied beds presented in this table):
Potential Use: * l
i
(9 operating beds) x (2 treatments/day) x (5 days/week) = 90 treatments/wk i
Actual Use:
(8 used beds) x (2 treatments/day) x (3 days) = 48
(7 used beds) x (1 treatment/day) x (2 days) = 14 i
62 treatments/wk . |
Percent Usage: i
62 treatments/wk :
90 treatments/wk = 68.9%
Hemodialysis Occupied Bed Equivalent:
i
(9 operating beds) x (0.689) = 6.2 "occupied beds" !
51
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APPENDIX C. MAJOR GEHERAflHG WARDS II HEW YORK AHD HKWj JERSEY1
Rank Ordering
Ward
Lab (including pathological)
Operating Room
Medical /Surgical
Dialysis
Emiirg«ncy Room
Labor & Delivery
ICUa/CCU
Nursing Unit
OB/GYH
Patiant Floor /Rooa
Oncology
Pharmacy
Ambulatory
Endoscopy
»
laolation Room*
Shock Traat»«ttt
Long Term Car*
TOTAL RESPONSES
Largest
Source
15
11
2
3
0
2
1
1
1
0
0
0
0
0
0
0
0
36
2nd
Largest
Source
9
12
2
1
5
0
I
1
1
0
1
1
0
0
0
1
1
36
3rd
Largest
Source
6
4
3
0
5
4
4
0
1
1
1
0
1
0
0
0
0
30
4th
Largest
Source
0
1
2 .
;l
5
0
8
1
2
3
1
1
0
1
0
0
0
26
3th
Largest
Source
0
1
2
0
8
1 .
4
I
4
1
0
0
0
1
1
0
0
24
Note: Sample size » 54
1 Taken from Characterization of Medical Waste
Disposal Practices in New
York and
New Jersey.
Generation
January 30,
-V.
and Treatment and
1989.
52
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GLOSSARY !
Chuck- Disposable linen protector.
i
Culture - A growth of microorganisms or other living cells in special media. :
Cuvette - A glass container used for examination of materials in the ultraviolet or visible region of
the spectrum. i
Dialyzer - An apparatus for drawing different components of a body fluid. i
V. \
Petridish- a shallow vessel of glass or other material for making bacterial cultures. \
Pipettes - A glass or transparent plastic tube used in measuring or transferring small quantities of
liquid. ;
Posted. - Supplies available from the Medical Center's central supply warehouse. !
Sharps - These include hypodermic needles, syringes, pipettes, scalpel blades, and needles.
Sharps ,
containers - A container in which sharps are disposed.
Unposted - Supplies not available through SPD that must be ordered directly from a medical supply
distributor. |
VACUTAINER- Blood collection sets. !
53
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